Provider Demographics
NPI:1447783816
Name:MCCOLLUM, KELLY (MSOTR/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7506 COVINGTON HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6152
Mailing Address - Country:US
Mailing Address - Phone:405-919-8142
Mailing Address - Fax:
Practice Address - Street 1:7506 COVINGTON HOLLOW LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6152
Practice Address - Country:US
Practice Address - Phone:405-919-8142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT1754225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics