Provider Demographics
NPI:1417136284
Name:MCCOLLUM, SHARON JENNENE (OTR)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:JENNENE
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2377 WILLOBRAE DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-3841
Mailing Address - Country:US
Mailing Address - Phone:409-363-9906
Mailing Address - Fax:
Practice Address - Street 1:3333 N FOSTER MALDONADO BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-5893
Practice Address - Country:US
Practice Address - Phone:830-773-5321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108930225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX108930OtherO. T. LICENSE