Healthcare Provider Details

I. General information

NPI: 1972662179
Provider Name (Legal Business Name): PAUL EDWARD MCCULLOUGH MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2441 JACKSON ST
SAN FRANCISCO CA
94115-1324
US

IV. Provider business mailing address

2441 JACKSON ST
SAN FRANCISCO CA
94115-1324
US

V. Phone/Fax

Practice location:
  • Phone: 415-346-6384
  • Fax: 415-346-1803
Mailing address:
  • Phone: 415-346-6384
  • Fax: 415-346-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number33485
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: