Healthcare Provider Details

I. General information

NPI: 1538787726
Provider Name (Legal Business Name): GARDNER MCCULLOUGH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 RICHMOND HWY # 1192
ALEXANDRIA VA
22305-3044
US

IV. Provider business mailing address

3301 RICHMOND HWY # 1192
ALEXANDRIA VA
22305-3044
US

V. Phone/Fax

Practice location:
  • Phone: 571-596-7864
  • Fax: 833-542-3318
Mailing address:
  • Phone: 443-417-7463
  • Fax: 833-542-3318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number25268
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: