Provider Demographics
NPI:1922181122
Name:O'DELL MCCOLLUM, DELORES ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DELORES
Middle Name:ANN
Last Name:O'DELL MCCOLLUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:ODELL MCCOLLUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2100 18TH AVENUE, STE 6
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201
Mailing Address - Country:US
Mailing Address - Phone:309-788-0730
Mailing Address - Fax:309-788-0733
Practice Address - Street 1:2100 18TH AVENUE, STE 6
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201
Practice Address - Country:US
Practice Address - Phone:309-788-0730
Practice Address - Fax:309-788-0733
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005753103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00855Medicaid