Provider Demographics
NPI:1073217436
Name:MCCULLOUGH, EILEEN MARIE
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:MARIE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W HILLSDALE ST APT 4
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90302-5885
Mailing Address - Country:US
Mailing Address - Phone:310-409-9408
Mailing Address - Fax:
Practice Address - Street 1:120 W HILLSDALE ST APT 4
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-5885
Practice Address - Country:US
Practice Address - Phone:310-409-9408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty