Provider Demographics
NPI:1982046215
Name:MCCOLLUM, BRENDAN JAMES
Entity type:Individual
Prefix:DR
First Name:BRENDAN
Middle Name:JAMES
Last Name:MCCOLLUM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2015
Mailing Address - Country:US
Mailing Address - Phone:706-499-1814
Mailing Address - Fax:
Practice Address - Street 1:4801 VETERANS DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2015
Practice Address - Country:US
Practice Address - Phone:941-753-0064
Practice Address - Fax:941-753-2977
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9633103TC0700X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47037660631Medicaid
NE10026139700Medicaid