Provider Demographics
NPI:1083802755
Name:HOLLER, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HOLLER
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 1:1970 BREAKERS DR
Mailing Address - Street 2:
Mailing Address - City:BARNEGAT
Mailing Address - State:NJ
Mailing Address - Zip Code:08005-2646
Mailing Address - Country:US
Mailing Address - Phone:732-610-7534
Mailing Address - Fax:
Practice Address - Street 1:1064 S MAIN ST
Practice Address - Street 2:BLDG 1E ROOM 203
Practice Address - City:WEST CREEK
Practice Address - State:NJ
Practice Address - Zip Code:08092-2912
Practice Address - Country:US
Practice Address - Phone:732-610-7534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC053131001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0169412Medicaid