Provider Demographics
NPI:1962919308
Name:COLCLOUGH, HOLLY (LMT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:COLCLOUGH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27999 OLD STH WALKER RD STE B
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:LA
Mailing Address - Zip Code:70785-6048
Mailing Address - Country:US
Mailing Address - Phone:225-271-4083
Mailing Address - Fax:
Practice Address - Street 1:27999 OLD STH WALKER RD STE B
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:LA
Practice Address - Zip Code:70785-6048
Practice Address - Country:US
Practice Address - Phone:225-271-4083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA8463225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA271739208OtherBLUE CROSS BLUE SHIELD