Provider Demographics
NPI:1184403735
Name:MCCOLLOUGH, TALESHIA MONAE
Entity type:Individual
Prefix:
First Name:TALESHIA
Middle Name:MONAE
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 1:22011 FERN ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-3943
Mailing Address - Country:US
Mailing Address - Phone:248-767-6720
Mailing Address - Fax:
Practice Address - Street 1:21705 MADA AVE
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-7504
Practice Address - Country:US
Practice Address - Phone:248-767-6720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide