Provider Demographics
NPI:1588202337
Name:MCCOLLEY, BRANDON MICHAEL (SLP)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:MCCOLLEY
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10324 CANYON RD E STE 203
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-1013
Mailing Address - Country:US
Mailing Address - Phone:253-471-2727
Mailing Address - Fax:253-471-2730
Practice Address - Street 1:10324 CANYON RD E STE 203
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-1013
Practice Address - Country:US
Practice Address - Phone:253-471-2727
Practice Address - Fax:253-471-2730
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ016464235Z00000X
WALL61018048235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist