Provider Demographics
NPI:1588663322
Name:MCCOLLOCH, THOMAS L (LCSW)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:MCCOLLOCH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 RIDGEWAY PL
Mailing Address - Street 2:STE 100
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2092
Mailing Address - Country:US
Mailing Address - Phone:423-442-2622
Mailing Address - Fax:423-442-5760
Practice Address - Street 1:1206 HIGHWAY 411
Practice Address - Street 2:
Practice Address - City:VONORE
Practice Address - State:TN
Practice Address - Zip Code:37885-2455
Practice Address - Country:US
Practice Address - Phone:423-884-7271
Practice Address - Fax:423-884-3277
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-106601041C0700X
TN37411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11261845OtherCAQH
TN3921436Medicaid