Healthcare Provider Details

I. General information

NPI: 1346674165
Provider Name (Legal Business Name): ELAINE J MCCULLOUGH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LONNIE MCCULLOUGH LCSW

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HARPER DR
MOORESTOWN NJ
08057-3208
US

IV. Provider business mailing address

251 HENDRICKSON AVE
EDGEWATER PARK NJ
08010-2018
US

V. Phone/Fax

Practice location:
  • Phone: 856-552-1300
  • Fax:
Mailing address:
  • Phone: 609-877-2860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC04853000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: