Provider Demographics
NPI:1003990607
Name:MCCULLOUGH, AIMEE E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AIMEE
Middle Name:E
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 SPLIT RAIL LN
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-3832
Mailing Address - Country:US
Mailing Address - Phone:808-372-7002
Mailing Address - Fax:808-372-7002
Practice Address - Street 1:9881 BROKENLAND PKWY
Practice Address - Street 2:105
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1172
Practice Address - Country:US
Practice Address - Phone:808-372-7002
Practice Address - Fax:808-372-7002
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY461103TC0700X
MD04720103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI07140002Medicaid
HI0000092858OtherHMSA
HI07140002Medicaid