MEDICARE: MARINA MCCOLLOM MA, T-LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	111322	IA

General Provider Information

NPI Number	:	1760133094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARINA MCCOLLOM MA, T-LMHC

Provider Business Mailing Address
First Line	:	1603 22ND ST STE 200
Second Line	:
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-1410
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1603 22ND ST STE 200
Second Line	:
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-1410
Country	:	US
Telephone Number	:	515-601-0411
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2022
Last Update Date	:	01/18/2022

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