1649246935 NPI number — MS. LISA MICHELLE MCCULLOCH LPC

Table of content: (NPI 1821108812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649246935 NPI number — MS. LISA MICHELLE MCCULLOCH LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCULLOCH
Provider First Name:
LISA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KENYON
Provider Other First Name:
LISA
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1649246935
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1222 DUNLOE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-207-1391
Provider Business Mailing Address Fax Number:
636-207-1391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14377 WOODLAKE DR
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-576-6493
Provider Business Practice Location Address Fax Number:
314-576-7319
Provider Enumeration Date:
02/27/2006

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: 101Y00000X , with the licence number:  2001004734 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 691209 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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