Healthcare Provider Details

I. General information

NPI: 1417244716
Provider Name (Legal Business Name): BRIAN PATRICK MCCULLOUGH LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 NICOLLET AVE
MINNEAPOLIS MN
55403-3791
US

IV. Provider business mailing address

1801 NICOLLET AVE
MINNEAPOLIS MN
55403-3791
US

V. Phone/Fax

Practice location:
  • Phone: 612-596-9438
  • Fax: 612-879-3824
Mailing address:
  • Phone: 612-596-9438
  • Fax: 612-879-3824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number310
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: