Provider Demographics
NPI:1780208959
Name:MCCULLOUGH, BRIAN THOMAS (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:THOMAS
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34406 N. 27TH DRIVE
Mailing Address - Street 2:SUITE 140 OFFICE 103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-6082
Mailing Address - Country:US
Mailing Address - Phone:623-688-1508
Mailing Address - Fax:
Practice Address - Street 1:34406 N. 27TH DRIVE
Practice Address - Street 2:SUITE 140 OFFICE 103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-6082
Practice Address - Country:US
Practice Address - Phone:623-688-1508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ241813363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty