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General NPI Number Information
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NPI Number | 1588663322
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Entity Type | Individual
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Provider Name | THOMAS L MCCOLLOCH LCSW
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Gender | Male
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Dates
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Enumeration Date | 07/14/2005
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Last Update Date | 09/27/2019
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Provider Practice Location Address
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Address Line | 1206 HIGHWAY 411
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City | VONORE
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State | TN
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Zip | 37885-2455
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Country | US
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Telephone | 423-884-7271
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Fax | 423-884-3277
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Provider Business Mailing Address
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Address Line | 1009 RIDGEWAY PL STE 100
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City | FARMINGTON
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State | NM
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Zip | 87401-2092
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Country | US
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Telephone | 423-442-2622
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Fax | 423-442-5760
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C-10660
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License Number State | NM
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