Provider Demographics
NPI:1215494737
Name:MCCOLLUM, JOHN HENRY JR
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:HENRY
Last Name:MCCOLLUM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 CONGRESS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-3427
Mailing Address - Country:US
Mailing Address - Phone:931-624-8339
Mailing Address - Fax:
Practice Address - Street 1:80 CONGRESS ST STE 101
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3427
Practice Address - Country:US
Practice Address - Phone:931-624-8339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)