Provider Demographics
NPI:1245029529
Name:MCCOLLOUGH, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:MCCOLLOUGH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 FULLER RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-3006
Mailing Address - Country:US
Mailing Address - Phone:850-566-9917
Mailing Address - Fax:
Practice Address - Street 1:1318 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-6506
Practice Address - Country:US
Practice Address - Phone:850-656-6606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-03
Last Update Date:2025-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA75655225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist