MEDICARE: MR. PAUL CHARLES MCCOLLUM LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	305758	MN

General Provider Information

NPI Number	:	1841996451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PAUL CHARLES MCCOLLUM LADC

Provider Business Mailing Address
First Line	:	14300 34TH AVE N APT 338
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55447-5207
Country	:	US
Telephone Number	:	716-380-8177
Fax Number	:

Provider Business Practice Location Address
First Line	:	10077 DOGWOOD ST NW STE 110
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-5285
Country	:	US
Telephone Number	:	651-777-5222
Fax Number	:

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

Provider Enumeration Date	:	02/06/2023
Last Update Date	:	09/07/2024

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