Provider Demographics
NPI:1740562065
Name:MCCOLLUM, MARCELLA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WASHINGTON SQ
Mailing Address - Street 2:SH 115
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95192-0079
Mailing Address - Country:US
Mailing Address - Phone:408-924-3679
Mailing Address - Fax:
Practice Address - Street 1:1 WASHINGTON SQ
Practice Address - Street 2:SH 115
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95192-0079
Practice Address - Country:US
Practice Address - Phone:408-924-3679
Practice Address - Fax:408-924-3641
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17246235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist