Provider Demographics
NPI:1225227101
Name:HOLLOMAN, MELISSA DAWN (LISW-CP & AP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
Last Name:HOLLOMAN
Suffix:
Gender:F
Credentials:LISW-CP & AP
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:HOLLOMAN
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW-CP & AP
Mailing Address - Street 1:279 N GROVE MEDICAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303
Mailing Address - Country:US
Mailing Address - Phone:843-302-2211
Mailing Address - Fax:
Practice Address - Street 1:279 N GROVE MEDICAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303
Practice Address - Country:US
Practice Address - Phone:843-302-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4989101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 104100000X, 1041C0700X, 106H00000X
101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ322560281OtherMEDICARE