Provider Demographics
NPI:1629298286
Name:MCCULLOCH, LEONARD
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:
Last Name:MCCULLOCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24477 BUCHANAN CT APT 1887
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2161
Mailing Address - Country:US
Mailing Address - Phone:248-476-9329
Mailing Address - Fax:248-476-4990
Practice Address - Street 1:24477 BUCHANAN CT APT 1887
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-2161
Practice Address - Country:US
Practice Address - Phone:248-476-9329
Practice Address - Fax:248-476-4990
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001838103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist