=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982046215
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. BRENDAN JAMES MCCOLLUM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2013
-----------------------------------------------------
Last Update Date | 03/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4801 VETERANS DR
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56303-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-753-0064
-----------------------------------------------------
Fax | 941-753-2977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4801 VETERANS DR
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56303-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-499-1814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 9633
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------