Provider Demographics
NPI:1306404975
Name:BANDY, HOLLIE JEWEL (LPC)
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:JEWEL
Last Name:BANDY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-453-6716
Practice Address - Street 1:620 E LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-2009
Practice Address - Country:US
Practice Address - Phone:330-455-0374
Practice Address - Fax:330-453-6716
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC2002760101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0351245Medicaid