Provider Demographics
NPI:1679751325
Name:MCCULLOUGH, THOMAS A (LPC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 W SEED FARM RD
Mailing Address - Street 2:NEW BEGININGS BUILDING
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247-0038
Mailing Address - Country:US
Mailing Address - Phone:602-528-7149
Mailing Address - Fax:602-528-1374
Practice Address - Street 1:483 W SEED FARM RD
Practice Address - Street 2:NEW BEGININGS BUILDING
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247-0038
Practice Address - Country:US
Practice Address - Phone:602-528-7149
Practice Address - Fax:602-528-1374
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC0334101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ346214Medicaid