Provider Demographics
NPI:1275315699
Name:MYRICK, HOLLY JENNEAN
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JENNEAN
Last Name:MYRICK
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 1:552 CANYON DR UNIT 32
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-3694
Mailing Address - Country:US
Mailing Address - Phone:805-431-3372
Mailing Address - Fax:
Practice Address - Street 1:23181 LA CADENA DR STE 103
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1479
Practice Address - Country:US
Practice Address - Phone:760-500-3325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142209106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist