Provider Demographics
NPI:1063035152
Name:NELSON, HOLLY JOY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JOY
Last Name:NELSON
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 1:11894 S LANDOU DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-6805
Mailing Address - Country:US
Mailing Address - Phone:801-362-0326
Mailing Address - Fax:
Practice Address - Street 1:11894 S LANDOU DR
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-6805
Practice Address - Country:US
Practice Address - Phone:801-362-0326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1164073086Medicaid