MEDICARE: DR. MARION GAMBLE MCCOLLUM ED.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	895	NC
2	103TC1900X	Counseling Psychologist	895	NC

General Provider Information

NPI Number	:	1033198841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARION GAMBLE MCCOLLUM ED.D.

Provider Business Mailing Address
First Line	:	912 N. ELM ST.
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27401-1513
Country	:	US
Telephone Number	:	336-274-4669
Fax Number	:	336-274-4749

Provider Business Practice Location Address
First Line	:	912 N. ELM ST.
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27401-1513
Country	:	US
Telephone Number	:	336-274-4669
Fax Number	:	336-274-4749

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	11/10/2008

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