Provider Demographics
NPI:1396906285
Name:COLLOM, CHAD (RN, MSN, PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:CHAD
Middle Name:
Last Name:COLLOM
Suffix:
Gender:M
Credentials:RN, MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 MARILLA DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-5906
Mailing Address - Country:US
Mailing Address - Phone:214-566-8727
Mailing Address - Fax:
Practice Address - Street 1:2206 MARILLA
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201
Practice Address - Country:US
Practice Address - Phone:214-566-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX675826363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health