Provider Demographics
NPI:1346454725
Name:MCCOLLUM, MELVENE DIANE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:MELVENE
Middle Name:DIANE
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8466 PIEDMONT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3068
Mailing Address - Country:US
Mailing Address - Phone:313-582-5069
Mailing Address - Fax:
Practice Address - Street 1:8600 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2142
Practice Address - Country:US
Practice Address - Phone:313-875-7601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010151541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical