Provider Demographics
NPI:1306076740
Name:MCCOLLUM, JOAN MILDRED (COTA/L)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:MILDRED
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-2149
Mailing Address - Country:US
Mailing Address - Phone:413-786-6774
Mailing Address - Fax:
Practice Address - Street 1:65 COOPER ST
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-2149
Practice Address - Country:US
Practice Address - Phone:413-786-6774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2840224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant