Provider Demographics
NPI:1053903591
Name:MCCULLOUGH, MARYANNA MAY (OTA)
Entity type:Individual
Prefix:MS
First Name:MARYANNA
Middle Name:MAY
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 6TH ST APT 301
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2383
Mailing Address - Country:US
Mailing Address - Phone:605-630-6732
Mailing Address - Fax:
Practice Address - Street 1:1310 6TH ST APT 301
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2383
Practice Address - Country:US
Practice Address - Phone:605-630-6732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002230224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant