Provider Demographics
NPI:1295785210
Name:MCCOLLUM, MICHAEL SHAWN (LMSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SHAWN
Last Name:MCCOLLUM
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SAN PEDRO DR SE DEPT VA
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5153
Mailing Address - Country:US
Mailing Address - Phone:505-503-3012
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO DR SE DEPT VA
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:505-503-3012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41557104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker