Provider Demographics
NPI:1083012066
Name:JOHNSON, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:JOHNSON
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 1:3113 1ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52405-4524
Mailing Address - Country:US
Mailing Address - Phone:319-560-0230
Mailing Address - Fax:319-298-0970
Practice Address - Street 1:3113 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52405-4524
Practice Address - Country:US
Practice Address - Phone:319-560-0230
Practice Address - Fax:319-298-0970
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0101342Medicaid