=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538787726
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARDNER MCCULLOUGH LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2020
-----------------------------------------------------
Last Update Date | 12/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3301 RICHMOND HWY # 1192
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22305-3044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-596-7864
-----------------------------------------------------
Fax | 833-542-3318
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3301 RICHMOND HWY # 1192
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22305-3044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-417-7463
-----------------------------------------------------
Fax | 833-542-3318
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 25268
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------