Provider Demographics
NPI:1063501245
Name:WILLIS, HOLLY (CCC/SLP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:BRANHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC/SLP
Mailing Address - Street 1:8312 WHITE STALLION TRL
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-6899
Mailing Address - Country:US
Mailing Address - Phone:469-952-3787
Mailing Address - Fax:
Practice Address - Street 1:1201 E 15TH ST
Practice Address - Street 2:SUITE 304
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-6238
Practice Address - Country:US
Practice Address - Phone:972-424-0148
Practice Address - Fax:972-422-5275
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19630235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T4241Medicare UPIN
TX7229664Medicare UPIN