Provider Demographics
NPI:1003453440
Name:SLY, HOLLY (MA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:SLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:GLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 S EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-4929
Mailing Address - Country:US
Mailing Address - Phone:304-256-7100
Mailing Address - Fax:
Practice Address - Street 1:101 S EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4929
Practice Address - Country:US
Practice Address - Phone:304-256-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1239103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist