Provider Demographics
NPI:1275049165
Name:MAHLUM, HOLLIE MARISSA
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:MARISSA
Last Name:MAHLUM
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 1:7261 W CHARLESTON BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-1679
Mailing Address - Country:US
Mailing Address - Phone:702-396-0101
Mailing Address - Fax:702-222-0212
Practice Address - Street 1:7261 W CHARLESTON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-1679
Practice Address - Country:US
Practice Address - Phone:702-396-0101
Practice Address - Fax:702-222-0212
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-17-45110106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician