1003990607 NPI number — DR. AIMEE E MCCULLOUGH PSYD

Table of content: DR. AIMEE E MCCULLOUGH PSYD (NPI 1003990607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003990607 NPI number — DR. AIMEE E MCCULLOUGH PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCULLOUGH
Provider First Name:
AIMEE
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003990607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3525 SPLIT RAIL LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLICOTT CITY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21042-3832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-372-7002
Provider Business Mailing Address Fax Number:
808-372-7002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9881 BROKENLAND PKWY
Provider Second Line Business Practice Location Address:
105
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21046-1172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-372-7002
Provider Business Practice Location Address Fax Number:
808-372-7002
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY461 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 04720 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07140002 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000092858 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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