Provider Demographics
NPI:1043694888
Name:HOLLY, ETHLYN
Entity Type:Individual
Prefix:
First Name:ETHLYN
Middle Name:
Last Name:HOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:MD
Mailing Address - Zip Code:21639-0029
Mailing Address - Country:US
Mailing Address - Phone:410-404-4625
Mailing Address - Fax:
Practice Address - Street 1:101 S ACADEMY ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:MD
Practice Address - Zip Code:21639-1643
Practice Address - Country:US
Practice Address - Phone:410-404-4625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MD17713104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker