Provider Demographics
NPI:1770767352
Name:MCCULLOUGH, ELAINE KIMBERLY (MA)
Entity type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:KIMBERLY
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3018 SUNSET HARBOR CT
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-0555
Mailing Address - Country:US
Mailing Address - Phone:702-249-1888
Mailing Address - Fax:
Practice Address - Street 1:2780 S JONES BLVD STE 100A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5625
Practice Address - Country:US
Practice Address - Phone:702-820-3061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPH1535101YM0800X
TN3374101YP2500X
NV1148101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1770767352Medicaid
TN1770767352Medicaid