Provider Demographics
NPI:1588202337
Name:MCCOLLEY, BRANDON MICHAEL (SLP)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:MCCOLLEY
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 BRIDLE CREEK ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-4939
Mailing Address - Country:US
Mailing Address - Phone:602-708-8921
Mailing Address - Fax:
Practice Address - Street 1:1942 BRIDLE CREEK ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-4939
Practice Address - Country:US
Practice Address - Phone:602-708-8921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101008421235Z00000X
WALL61018048235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty