Provider Demographics
NPI:1609984210
Name:MCCOLLUM, SALLY (PHD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6078
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-6078
Mailing Address - Country:US
Mailing Address - Phone:208-726-8926
Mailing Address - Fax:208-726-8926
Practice Address - Street 1:171 W. 1ST ST #1
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-6078
Practice Address - Country:US
Practice Address - Phone:208-726-8926
Practice Address - Fax:208-726-8926
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY 237103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1680186Medicare PIN