Provider Demographics
NPI:1225261332
Name:MCCOLLUM, HOLLY RENEE (PT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:RENEE
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:RENEE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2981 SW 22ND ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-4356
Mailing Address - Country:US
Mailing Address - Phone:954-328-6195
Mailing Address - Fax:954-783-8161
Practice Address - Street 1:2981 SW 22ND ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-4356
Practice Address - Country:US
Practice Address - Phone:954-328-6195
Practice Address - Fax:954-783-8161
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL249392251P0200X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001377000Medicaid