Provider Demographics
NPI:1245597848
Name:HOLLOWAY, THADEUS MANDRALL (LPC)
Entity Type:Individual
Prefix:MR
First Name:THADEUS
Middle Name:MANDRALL
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 172
Mailing Address - Street 2:305 WEST SPRING STREET
Mailing Address - City:MOUNT VERNON
Mailing Address - State:GA
Mailing Address - Zip Code:30445-0172
Mailing Address - Country:US
Mailing Address - Phone:912-423-1000
Mailing Address - Fax:912-583-0115
Practice Address - Street 1:305 W SPRING ST
Practice Address - Street 2:BOX 172
Practice Address - City:MOUNT VERNON
Practice Address - State:GA
Practice Address - Zip Code:30445-2837
Practice Address - Country:US
Practice Address - Phone:912-423-1000
Practice Address - Fax:912-583-0115
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GALPC006790101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health