MEDICARE: MR. GARDNER MCCULLOUGH LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	25268	MD

General Provider Information

NPI Number	:	1538787726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARDNER MCCULLOUGH LCSW

Provider Business Mailing Address
First Line	:	3301 RICHMOND HWY # 1192
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22305-3044
Country	:	US
Telephone Number	:	443-417-7463
Fax Number	:	833-542-3318

Provider Business Practice Location Address
First Line	:	3301 RICHMOND HWY # 1192
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22305-3044
Country	:	US
Telephone Number	:	571-596-7864
Fax Number	:	833-542-3318

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2020
Last Update Date	:	12/17/2025

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