Provider Demographics
NPI:1467867952
Name:MCCOLLUM, JOHN (CAC III, CPS II)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:M
Credentials:CAC III, CPS II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-1899
Mailing Address - Country:US
Mailing Address - Phone:303-441-1540
Mailing Address - Fax:303-441-1576
Practice Address - Street 1:3450 BROADWAY
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-1899
Practice Address - Country:US
Practice Address - Phone:303-441-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0006407101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)