Provider Demographics
NPI:1407385321
Name:MCCOLLUM, DIANE L (MA, PHD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 TUGGLE RD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4037
Mailing Address - Country:US
Mailing Address - Phone:678-920-2608
Mailing Address - Fax:
Practice Address - Street 1:2940 HORIZON PARK DR
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-7251
Practice Address - Country:US
Practice Address - Phone:678-920-2608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral