Provider Demographics
NPI:1003078437
Name:HOLLIST TREATMENT FOR ADOLESCENTS AND FAMILIES
Entity Type:Organization
Organization Name:HOLLIST TREATMENT FOR ADOLESCENTS AND FAMILIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CODY
Authorized Official - Middle Name:STONEWALL
Authorized Official - Last Name:HOLLIST
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LIMHP, LIMFT
Authorized Official - Phone:402-202-0506
Mailing Address - Street 1:2111 W MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68522-1421
Mailing Address - Country:US
Mailing Address - Phone:402-202-0577
Mailing Address - Fax:402-438-5330
Practice Address - Street 1:2111 W MULBERRY ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68522-1421
Practice Address - Country:US
Practice Address - Phone:402-202-0577
Practice Address - Fax:402-438-5330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE272251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health