Provider Demographics
NPI:1710699012
Name:MCCOLLOUGH, HENRIETTA
Entity Type:Individual
Prefix:MRS
First Name:HENRIETTA
Middle Name:
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:PO BOX 454
Mailing Address - Street 2:
Mailing Address - City:CATAWBA
Mailing Address - State:SC
Mailing Address - Zip Code:29704-0454
Mailing Address - Country:US
Mailing Address - Phone:803-431-0197
Mailing Address - Fax:
Practice Address - Street 1:5547 HOWZE RD
Practice Address - Street 2:
Practice Address - City:CATAWBA
Practice Address - State:SC
Practice Address - Zip Code:29704-7750
Practice Address - Country:US
Practice Address - Phone:803-431-0197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-18092278H0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCIHCP-1809Medicaid