Healthcare Provider Details

I. General information

NPI: 1629298286
Provider Name (Legal Business Name): MR. LEONARD MCCULLOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24477 BUCHANAN CT APT 1887
FARMINGTON HILLS MI
48335-2161
US

IV. Provider business mailing address

24477 BUCHANAN CT APT 1887
FARMINGTON HILLS MI
48335-2161
US

V. Phone/Fax

Practice location:
  • Phone: 248-476-9329
  • Fax: 248-476-4990
Mailing address:
  • Phone: 248-476-9329
  • Fax: 248-476-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301001838
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: