Provider Demographics
NPI:1609616226
Name:MCCULLOUGH, BEVERLY
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 PECAN TREE DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36109-1823
Mailing Address - Country:US
Mailing Address - Phone:334-647-5710
Mailing Address - Fax:
Practice Address - Street 1:411 PECAN TREE DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-1823
Practice Address - Country:US
Practice Address - Phone:857-829-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician