Provider Demographics
NPI:1285289249
Name:MCCOLLOCH, MICAH (PTA)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:MCCOLLOCH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 SPARKMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:DOYLE
Mailing Address - State:TN
Mailing Address - Zip Code:38559-3235
Mailing Address - Country:US
Mailing Address - Phone:931-607-4885
Mailing Address - Fax:
Practice Address - Street 1:815 S WALNUT AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-5956
Practice Address - Country:US
Practice Address - Phone:931-528-5516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7124225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant