1467518415 NPI number — DR. JILL D. MCCOLLUM PHD - LCPC

Table of content: DR. JILL D. MCCOLLUM PHD - LCPC (NPI 1467518415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467518415 NPI number — DR. JILL D. MCCOLLUM PHD - LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCOLLUM
Provider First Name:
JILL
Provider Middle Name:
D.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD - LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467518415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
650 ISLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG ISLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04050-3311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-799-9600
Provider Business Mailing Address Fax Number:
207-799-9600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1396 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04106-4111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-799-9600
Provider Business Practice Location Address Fax Number:
207-799-9600
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  CC2230 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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