Provider Demographics
NPI:1235761180
Name:HOLLIS, DESTENY
Entity Type:Individual
Prefix:
First Name:DESTENY
Middle Name:
Last Name:HOLLIS
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 1:2785 SOM CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-6501
Mailing Address - Country:US
Mailing Address - Phone:216-278-0288
Mailing Address - Fax:
Practice Address - Street 1:2785 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-6501
Practice Address - Country:US
Practice Address - Phone:216-278-0288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
OHRBT-20-146237106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251B00000XAgenciesCase Management