Provider Demographics
NPI:1487166203
Name:MCCULLOCH, MELISSA ANN (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:BUNDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19674
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9674
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-585-6890
Practice Address - Street 1:319 E MADISON ST FL 3
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1035
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-585-6890
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147-0180471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL147-018047OtherSTATE LICENSE