Provider Demographics
NPI:1346840097
Name:MCCOLLUM, MONIQUE
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5816 CREEDMOOR RD STE 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2310
Mailing Address - Country:US
Mailing Address - Phone:910-212-7800
Mailing Address - Fax:
Practice Address - Street 1:5816 CREEDMOOR RD STE 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-2310
Practice Address - Country:US
Practice Address - Phone:910-212-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician