Provider Demographics
NPI:1114092954
Name:WAKEFIELD, HOLLY S (LCMHC LPC)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:S
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:LCMHC LPC
Other - Prefix:MRS
Other - First Name:HOLLY
Other - Middle Name:A
Other - Last Name:STUART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:67 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:ST ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478
Mailing Address - Country:US
Mailing Address - Phone:802-524-8747
Mailing Address - Fax:
Practice Address - Street 1:67 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:ST ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478
Practice Address - Country:US
Practice Address - Phone:802-524-8747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000511101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007521Medicaid