Provider Demographics
NPI:1114961406
Name:MCCOLLOCH, MICHAEL ARNOLD (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ARNOLD
Last Name:MCCOLLOCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1346 ASHLEY SQ
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2949
Mailing Address - Country:US
Mailing Address - Phone:336-768-8023
Mailing Address - Fax:336-768-2382
Practice Address - Street 1:1346 ASHLEY SQ
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2949
Practice Address - Country:US
Practice Address - Phone:336-768-8023
Practice Address - Fax:336-768-2382
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC611103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000094Medicaid