Provider Demographics
NPI:1063295731
Name:MCCOLLUM, MARY ELIZABETH (P-LPC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:P-LPC
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:KAKALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:P-LPC, MED
Mailing Address - Street 1:331 N ROSE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-1500
Mailing Address - Country:US
Mailing Address - Phone:901-490-1589
Mailing Address - Fax:
Practice Address - Street 1:6915 CRUMPLER BLVD STE A
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1907
Practice Address - Country:US
Practice Address - Phone:731-577-1916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0953101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health