MEDICARE: MS. ELAINE KIMBERLY MCCULLOUGH MA

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	101YM0800X	Mental Health Counselor	PH1535	MS
2	101YP2500X	Professional Counselor	3374	TN
3	101YP2500X	Professional Counselor	1148	NV
4	101YM0800X	Mental Health Counselor	1148	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770767352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELAINE KIMBERLY MCCULLOUGH MA

Provider Business Mailing Address
First Line	:	3018 SUNSET HARBOR CT
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-0555
Country	:	US
Telephone Number	:	702-249-1888
Fax Number	:

Provider Business Practice Location Address
First Line	:	2780 S JONES BLVD STE 100A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5625
Country	:	US
Telephone Number	:	702-820-3061
Fax Number	:

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

Provider Enumeration Date	:	12/19/2007
Last Update Date	:	02/02/2021

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Directions to “ MS. ELAINE KIMBERLY MCCULLOUGH MA” Practice Location

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