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General NPI Number Information
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NPI Number | 1841996451
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Entity Type | Individual
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Provider Name | PAUL CHARLES MCCOLLUM LADC
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Gender | Male
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Dates
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Enumeration Date | 02/06/2023
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Last Update Date | 09/07/2024
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Provider Practice Location Address
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Address Line | 10077 DOGWOOD ST NW STE 110
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City | COON RAPIDS
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State | MN
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Zip | 55448-5285
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Country | US
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Telephone | 651-777-5222
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Fax |
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Provider Business Mailing Address
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Address Line | 14300 34TH AVE N APT 338
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City | PLYMOUTH
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State | MN
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Zip | 55447-5207
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Country | US
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Telephone | 716-380-8177
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Fax |
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 305758
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License Number State | MN
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