Provider Demographics
NPI:1336906395
Name:MCCOLLUM, XALICIA (PTA)
Entity Type:Individual
Prefix:
First Name:XALICIA
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6709 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SELLERS
Mailing Address - State:SC
Mailing Address - Zip Code:29592-7019
Mailing Address - Country:US
Mailing Address - Phone:843-617-9555
Mailing Address - Fax:
Practice Address - Street 1:228 SMITH CHAPEL RD
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-1917
Practice Address - Country:US
Practice Address - Phone:919-658-9522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225200000X
SC5042225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant