Provider Demographics
NPI:1609316884
Name:MCCOLLOUGH, DARRELL JR
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:
Last Name:MCCOLLOUGH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 RIVARA RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-1846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1414 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1515
Practice Address - Country:US
Practice Address - Phone:209-403-8209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor