Provider Demographics
NPI:1033198841
Name:MCCOLLUM, MARION GAMBLE (EDD)
Entity Type:Individual
Prefix:DR
First Name:MARION
Middle Name:GAMBLE
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 N. ELM ST.
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1513
Mailing Address - Country:US
Mailing Address - Phone:336-274-4669
Mailing Address - Fax:336-274-4749
Practice Address - Street 1:912 N. ELM ST.
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1513
Practice Address - Country:US
Practice Address - Phone:336-274-4669
Practice Address - Fax:336-274-4749
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC895103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1033198841Medicare Oscar/Certification
NC1033198841Medicare NSC
NC1033198841Medicare PIN
NC1033198841Medicare UPIN