Provider Demographics
NPI:1184748741
Name:MCCOLLOUGH, MOLLY (RD,LD)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MCCOLLOUGH
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4536 BARCLAY DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-5802
Mailing Address - Country:US
Mailing Address - Phone:770-458-8711
Mailing Address - Fax:770-458-8640
Practice Address - Street 1:4536 BARCLAY DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-5802
Practice Address - Country:US
Practice Address - Phone:770-458-8711
Practice Address - Fax:770-458-8640
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002656133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist