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General NPI Number Information
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NPI Number | 1902202054
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Entity Type | Individual
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Provider Name | PHYLLIS FERGUSON COLLUM LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/17/2014
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Last Update Date | 04/04/2024
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Provider Practice Location Address
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Address Line | 15539 DOBSON AVE
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City | DOLTON
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State | IL
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Zip | 60419-2708
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Country | US
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Telephone | 312-810-5203
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Fax | 773-654-3875
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Provider Business Mailing Address
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Address Line | 15539 DOBSON AVE
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City | DOLTON
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State | IL
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Zip | 60419-2708
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Country | US
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Telephone | 312-810-5203
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Fax | 773-654-3875
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 149015907
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 149015907
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149015907
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License Number State | IL
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