Provider Demographics
NPI:1336441443
Name:KOLLIE, ZUMO M (LCAS)
Entity type:Individual
Prefix:MR
First Name:ZUMO
Middle Name:M
Last Name:KOLLIE
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5856 OLD OAK RIDGE RD APT 703
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-8423
Mailing Address - Country:US
Mailing Address - Phone:336-508-1837
Mailing Address - Fax:
Practice Address - Street 1:5856 OLD OAK RIDGE RD APT 703
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-8423
Practice Address - Country:US
Practice Address - Phone:336-508-1837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)