Provider Demographics
NPI:1831424043
Name:MCCOLLOUGH, ESSIE
Entity type:Individual
Prefix:
First Name:ESSIE
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 1:475 N HIGHLAND ST
Mailing Address - Street 2:2A
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38122-4544
Mailing Address - Country:US
Mailing Address - Phone:901-488-7848
Mailing Address - Fax:901-323-1868
Practice Address - Street 1:475 N HIGHLAND ST
Practice Address - Street 2:2A
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38122-4544
Practice Address - Country:US
Practice Address - Phone:901-488-7848
Practice Address - Fax:901-323-1868
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-05
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN021157058172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver