Healthcare Provider Details

I. General information

NPI: 1770902702
Provider Name (Legal Business Name): CHRISTINE MCCOLLUM LICDC, OCPSII, MACM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTINE KRAEMER

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 TRAILWOOD DR
BOARDMAN OH
44512-5007
US

IV. Provider business mailing address

615 ELSINORE PL STE 200
CINCINNATI OH
45202-1459
US

V. Phone/Fax

Practice location:
  • Phone: 513-834-7063
  • Fax:
Mailing address:
  • Phone: 513-834-7063
  • Fax: 513-873-1567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC111100
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberOCPC1061
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.111100
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: