Provider Demographics
NPI:1225366677
Name:MCCOLLOUGH, LATOYA SHUNTEA
Entity Type:Individual
Prefix:MS
First Name:LATOYA
Middle Name:SHUNTEA
Last Name:MCCOLLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 UNION ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5115
Mailing Address - Country:US
Mailing Address - Phone:931-647-8257
Mailing Address - Fax:931-647-8257
Practice Address - Street 1:118 UNION ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5115
Practice Address - Country:US
Practice Address - Phone:931-647-8257
Practice Address - Fax:931-647-8257
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness