Provider Demographics
NPI:1699908194
Name:MCCOLLUM, MELANIE LYNN (CCDCI CDP)
Entity type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:LYNN
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:CCDCI CDP
Other - Prefix:MS
Other - First Name:MELANIE
Other - Middle Name:LYNN
Other - Last Name:MCCOLLUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCDCI CDP
Mailing Address - Street 1:25504 E LAKE ARMSTRONG RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-8139
Mailing Address - Country:US
Mailing Address - Phone:425-268-8805
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:25504 E LAKE ARMSTRONG RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223
Practice Address - Country:US
Practice Address - Phone:425-268-8805
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001196101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-0920666Medicaid