Provider Demographics
NPI:1316538630
Name:ALLEN, HOLLY (MA & PPS)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MA & PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 CREAMER RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23503-3923
Mailing Address - Country:US
Mailing Address - Phone:209-496-2288
Mailing Address - Fax:
Practice Address - Street 1:800 E CITY HALL AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-2723
Practice Address - Country:US
Practice Address - Phone:757-628-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0606822103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA33944Medicaid