Healthcare Provider Details

I. General information

NPI: 1780817916
Provider Name (Legal Business Name): JOHN MCCULLAGH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2009
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 QUENTIN RD STE 110
BROOKLYN NY
11234-4245
US

IV. Provider business mailing address

145 MORNINGSIDE AVE APT 1D
NEW YORK NY
10027-4348
US

V. Phone/Fax

Practice location:
  • Phone: 800-275-3243
  • Fax:
Mailing address:
  • Phone: 832-866-8115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number023722-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: