Provider Demographics
NPI:1144420464
Name:MCCOLLAM, TONJA
Entity Type:Individual
Prefix:
First Name:TONJA
Middle Name:
Last Name:MCCOLLAM
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:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-0688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 DONALD AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-2001
Practice Address - Country:US
Practice Address - Phone:620-331-1748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMSW 6966104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200437450AMedicaid