Provider Demographics
NPI:1770875924
Name:MCCULLOUGH, COLIN ALEXANDER (ATC, CSCS)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:ALEXANDER
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:41 STRATHMORE RD APT 6
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-7935
Mailing Address - Country:US
Mailing Address - Phone:413-329-6826
Mailing Address - Fax:
Practice Address - Street 1:140 COMMONWEALTH AVE
Practice Address - Street 2:YAWKEY CENTER- ROOM 108
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-3800
Practice Address - Country:US
Practice Address - Phone:617-552-9113
Practice Address - Fax:617-552-9101
Is Sole Proprietor?:No
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer