=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417625260
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLIOT PARADIS MCCULLOUGH LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2021
-----------------------------------------------------
Last Update Date | 09/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 NASSAU ST 3RD FL
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10038-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-416-5629
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 WESTMINSTER RD APT 2K
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11218-2828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-596-7338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 104664
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------