Healthcare Provider Details

I. General information

NPI: 1649227802
Provider Name (Legal Business Name): ELIZABETH LANE MCCULLOUGH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16836 NEWBURGH RD UPC LIVONIA
LIVONIA MI
48154
US

IV. Provider business mailing address

3800 WOODWARD AVE SUITE 702
DETROIT MI
48201-2061
US

V. Phone/Fax

Practice location:
  • Phone: 888-362-7792
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4101071482
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: