Provider Demographics
NPI:1770902702
Name:MCCOLLUM, CHRISTINE (LICDC, OCPSII, MACM)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:LICDC, OCPSII, MACM
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:KRAEMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:615 ELSINORE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1459
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:513-873-1567
Practice Address - Street 1:930 TRAILWOOD DR
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5007
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC111100101YA0400X
OHOCPC1061405300000X
OHLICDC.111100101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0199144Medicaid