Provider Demographics
NPI:1740319821
Name:MCCOLLUM, R. DOUGLAS (PHD)
Entity type:Individual
Prefix:DR
First Name:R.
Middle Name:DOUGLAS
Last Name:MCCOLLUM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 47TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3663
Mailing Address - Country:US
Mailing Address - Phone:309-762-3931
Mailing Address - Fax:309-762-4938
Practice Address - Street 1:2101 47TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3663
Practice Address - Country:US
Practice Address - Phone:309-762-3931
Practice Address - Fax:309-762-4938
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00213103T00000X
IA00512103TC2200X
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA58957OtherWELLMARK BCBS
IA58957OtherWELLMARK BCBS