Provider Demographics
NPI:1114463700
Name:HOLLOWAY, SHACONDA LARECE (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:SHACONDA
Middle Name:LARECE
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3239 JOPLIN LN
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-1197
Mailing Address - Country:US
Mailing Address - Phone:757-942-1987
Mailing Address - Fax:757-255-7139
Practice Address - Street 1:5268 GODWIN BLVD
Practice Address - Street 2:WESTERN TIDEWATER MENTAL HEALTH
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434
Practice Address - Country:US
Practice Address - Phone:757-255-7117
Practice Address - Fax:757-255-7139
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040094881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical