Provider Demographics
NPI:1730560574
Name:MCCOLLAUM, MARY WARREN (CNS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:WARREN
Last Name:MCCOLLAUM
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:
Other - Last Name:WARREN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNS
Mailing Address - Street 1:275 S MAIN ST
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-4815
Mailing Address - Country:US
Mailing Address - Phone:215-345-5665
Mailing Address - Fax:215-345-5700
Practice Address - Street 1:275 S MAIN ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-4815
Practice Address - Country:US
Practice Address - Phone:215-345-5665
Practice Address - Fax:215-345-5700
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education