Provider Demographics
NPI:1730924010
Name:MCCOLLOUGH, ANQUONETTA AVA
Entity type:Individual
Prefix:
First Name:ANQUONETTA
Middle Name:AVA
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 1:1240 W OWENS AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-2452
Mailing Address - Country:US
Mailing Address - Phone:702-410-5295
Mailing Address - Fax:
Practice Address - Street 1:2725 S JONES BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5605
Practice Address - Country:US
Practice Address - Phone:409-457-3688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No172V00000XOther Service ProvidersCommunity Health Worker