Provider Demographics
NPI:1245905876
Name:MCCOLLUM, DEANNA
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 ARLINGTON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-1300
Mailing Address - Country:US
Mailing Address - Phone:323-334-9000
Mailing Address - Fax:323-334-4437
Practice Address - Street 1:1749 14TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4342
Practice Address - Country:US
Practice Address - Phone:213-760-4362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician