Provider Demographics
NPI:1538787726
Name:MCCULLOUGH, GARDNER LEVERING II (LMSW)
Entity type:Individual
Prefix:MR
First Name:GARDNER
Middle Name:LEVERING
Last Name:MCCULLOUGH
Suffix:II
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5983 ROWANBERRY DR
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-5249
Mailing Address - Country:US
Mailing Address - Phone:443-417-7463
Mailing Address - Fax:
Practice Address - Street 1:8181 MAIN ST APT 2
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4929
Practice Address - Country:US
Practice Address - Phone:757-651-3001
Practice Address - Fax:757-222-3833
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25268104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker