Healthcare Provider Details

I. General information

NPI: 1033198841
Provider Name (Legal Business Name): MARION GAMBLE MCCOLLUM ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 N. ELM ST.
GREENSBORO NC
27401-1513
US

IV. Provider business mailing address

912 N. ELM ST.
GREENSBORO NC
27401-1513
US

V. Phone/Fax

Practice location:
  • Phone: 336-274-4669
  • Fax: 336-274-4749
Mailing address:
  • Phone: 336-274-4669
  • Fax: 336-274-4749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number895
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number895
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: