Basic Information
| Provider Information | |||||||||
| NPI: | 1669988671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLY | ||||||||
| FirstName: | CAITLIN | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 501 W BROADWAY STE 800 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921013546 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 W BROADWAY STE 800 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921013546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774182978 | ||||||||
| FaxNumber: | 9543420273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2017 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | 0-19-9527 | CA | N | 103K00000X | 1-21-48244 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.