Provider Demographics
NPI:1912104498
Name:MCCOLLOUGH, MELISSA ANN (LMP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MCCOLLOUGH
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 821
Mailing Address - Street 2:
Mailing Address - City:LOON LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99148-0821
Mailing Address - Country:US
Mailing Address - Phone:509-998-8582
Mailing Address - Fax:
Practice Address - Street 1:20 EAST J STREET SUITE B
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006
Practice Address - Country:US
Practice Address - Phone:509-276-8809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024298225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist