1730465311 NPI number — MR. JONATHAN PETER MCCULLOCH LLMSW

Table of content: MR. JONATHAN PETER MCCULLOCH LLMSW (NPI 1730465311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730465311 NPI number — MR. JONATHAN PETER MCCULLOCH LLMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCULLOCH
Provider First Name:
JONATHAN
Provider Middle Name:
PETER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LLMSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730465311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
COLONIAL WOODS CHRISTIAN COUNSELING CENTER
Provider Second Line Business Mailing Address:
1101 MILITARY STREET
Provider Business Mailing Address City Name:
PORT HURON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48060-5418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-984-5575
Provider Business Mailing Address Fax Number:
810-984-6433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
COLONIAL WOODS CHRISTIAN COUNSELING CENTER
Provider Second Line Business Practice Location Address:
1101 MILITARY STREET
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060-5418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-984-5575
Provider Business Practice Location Address Fax Number:
810-984-6433
Provider Enumeration Date:
10/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 3747P1801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 6851115199 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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