Healthcare Provider Details

I. General information

NPI: 1952953523
Provider Name (Legal Business Name): JILL MCCULLOCH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JILL BETH ROMANSKY

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 WOODMONT AVE STE 1101
BETHESDA MD
20814-7059
US

IV. Provider business mailing address

7910 WOODMONT AVE STE 1101
BETHESDA MD
20814-7059
US

V. Phone/Fax

Practice location:
  • Phone: 202-486-5552
  • Fax:
Mailing address:
  • Phone: 301-221-1591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number04555
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number04555
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: