Provider Demographics
NPI:1245575158
Name:GIFFORD, HOLLY MICHELLE (LPC-IT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:MICHELLE
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 SAGE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-1235
Mailing Address - Country:US
Mailing Address - Phone:262-358-2411
Mailing Address - Fax:
Practice Address - Street 1:W4051 COUNTY ROAD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4338
Practice Address - Country:US
Practice Address - Phone:262-741-3307
Practice Address - Fax:262-741-3315
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1416-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional