Basic Information
| Provider Information | |||||||||
| NPI: | 1780709584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | L.C.S.W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 S 48TH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727626683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4798722441 | ||||||||
| Practice Location | |||||||||
| Address1: | 2508 SE 20TH ST | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727124008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792739088 | ||||||||
| FaxNumber: | 4798452111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2096-C | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.