Provider Demographics
NPI:1164246815
Name:MCCOLLUM, KRISTINE CAROLINE (OTR)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:CAROLINE
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:CAROLINE
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 KLINE RD
Mailing Address - Street 2:
Mailing Address - City:PAXINOS
Mailing Address - State:PA
Mailing Address - Zip Code:17860-7014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:418 RAILROAD ST STE 102
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-1547
Practice Address - Country:US
Practice Address - Phone:570-360-8646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC020160225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty