Provider Demographics
NPI:1689604738
Name:MCCULLEY, ELIZABETH KATE (MS LPC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KATE
Last Name:MCCULLEY
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 MCKNIGHT RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0921
Mailing Address - Country:US
Mailing Address - Phone:903-824-5548
Mailing Address - Fax:
Practice Address - Street 1:4140 MCKNIGHT RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0921
Practice Address - Country:US
Practice Address - Phone:903-824-5548
Practice Address - Fax:903-255-0310
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19973101YP2500X, 101YP2500X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00435872Medicaid