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:
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Other - Credentials:
Mailing Address - Street 1:34225 N 27TH DR STE 140
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-6090
Mailing Address - Country:US
Mailing Address - Phone:602-492-3692
Mailing Address - Fax:602-698-9668
Practice Address - Street 1:34225 N 27TH DR STE 140
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-6090
Practice Address - Country:US
Practice Address - Phone:602-492-3692
Practice Address - Fax:602-698-9668
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2025-02-06
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