Healthcare Provider Details

I. General information

NPI: 1790972412
Provider Name (Legal Business Name): VIVIAN JUANITA MCCOLLUM PH.D., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 WASHINGTON AVE UNIT 809
SAINT LOUIS MO
63101-1174
US

IV. Provider business mailing address

1136 WASHINGTON AVE UNIT 809
SAINT LOUIS MO
63101-1174
US

V. Phone/Fax

Practice location:
  • Phone: 404-536-7586
  • Fax: 314-727-6067
Mailing address:
  • Phone: 404-536-7586
  • Fax: 314-727-6067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2015032865
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC004750
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: