Healthcare Provider Details

I. General information

NPI: 1598592362
Provider Name (Legal Business Name): TAJI ALI MCCULLOUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE
NEW YORK NY
10029-7491
US

IV. Provider business mailing address

470 W 141ST ST APT 4A
NEW YORK NY
10031-6208
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6262
  • Fax:
Mailing address:
  • Phone: 646-596-6150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number406347
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: