Provider Demographics
NPI:1811146624
Name:MCCULLOUGH, COLLEEN A (RPT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:A
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 EAST AVE
Mailing Address - Street 2:SUITE 2M
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5721
Mailing Address - Country:US
Mailing Address - Phone:203-866-5458
Mailing Address - Fax:203-866-3014
Practice Address - Street 1:586 E MIDDLE TPKE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3730
Practice Address - Country:US
Practice Address - Phone:860-645-3810
Practice Address - Fax:860-645-3814
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist