Provider Demographics
NPI:1235781121
Name:LAGO, HOLLY JEAN (LMSW)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JEAN
Last Name:LAGO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:JEAN
Other - Last Name:BARRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:677 E MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032-8525
Mailing Address - Country:US
Mailing Address - Phone:269-467-1000
Mailing Address - Fax:
Practice Address - Street 1:677 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032-8525
Practice Address - Country:US
Practice Address - Phone:269-467-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011031141041C0700X
MI68511031141041C0700X
MI68011154921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical