Provider Demographics
NPI:1417625260
Name:MCCULLOUGH, ELLIOT PARADIS (LMSW)
Entity Type:Individual
Prefix:MR
First Name:ELLIOT
Middle Name:PARADIS
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WESTMINSTER RD APT 2K
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-2828
Mailing Address - Country:US
Mailing Address - Phone:917-596-7338
Mailing Address - Fax:
Practice Address - Street 1:116 NASSAU ST
Practice Address - Street 2:3RD FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2402
Practice Address - Country:US
Practice Address - Phone:212-416-5629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-04
Last Update Date:2021-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1046641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty