Provider Demographics
NPI:1902202054
Name:FERGUSON COLLUM, PHYLLIS (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:
Last Name:FERGUSON COLLUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15539 DOBSON AVE
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-2708
Mailing Address - Country:US
Mailing Address - Phone:312-810-5203
Mailing Address - Fax:773-654-3875
Practice Address - Street 1:15539 DOBSON AVE
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-2708
Practice Address - Country:US
Practice Address - Phone:312-810-5203
Practice Address - Fax:773-654-3875
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149015907101YM0800X, 101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional