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NPI Code Detail

MEDICARE: MR. SEAN DOUGLAS MCCOLLOM

MEDICARE: MR. SEAN DOUGLAS MCCOLLOM
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
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1962849844
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. SEAN DOUGLAS MCCOLLOM
Provider Business Mailing Address
First Line : 5009 AUSTRIAN DR
Second Line :
City : LAS VEGAS
State : NV
Zip : 89130-2237
Country : US
Telephone Number : 702-738-6594
Fax Number :
Provider Business Practice Location Address
First Line : 5550 PAINTED MIRAGE RD STE 320
Second Line :
City : LAS VEGAS
State : NV
Zip : 89149-4584
Country : US
Telephone Number : 702-582-6129
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/31/2013
Last Update Date : 05/31/2013

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