Provider Demographics
NPI:1174040588
Name:HOLLOWAY, THERESA DANIELE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:DANIELE
Last Name:HOLLOWAY
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 1:14201 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1884
Mailing Address - Country:US
Mailing Address - Phone:707-205-6826
Mailing Address - Fax:
Practice Address - Street 1:8915 SW CENTER ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6307
Practice Address - Country:US
Practice Address - Phone:503-501-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health