Basic Information
| Provider Information | |||||||||
| NPI: | 1770902702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCOLLUM | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICDC, OCPSII, MACM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRAEMER | ||||||||
| OtherFirstName: | CHRISTINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 615 ELSINORE PL STE 200 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452021459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138347063 | ||||||||
| FaxNumber: | 5138731567 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 TRAILWOOD DR | ||||||||
| Address2: | |||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445125007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138347063 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2014 | ||||||||
| LastUpdateDate: | 11/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LICDC111100 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 405300000X | OCPC1061 | OH | N | 101YA0400X | LICDC.111100 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0199144 | 05 | OH | MEDICAID |