Provider Demographics
NPI:1326152737
Name:AVRIETTE, HOLLY (PHD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:AVRIETTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28824
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92198-0824
Mailing Address - Country:US
Mailing Address - Phone:858-487-2713
Mailing Address - Fax:858-487-4741
Practice Address - Street 1:11770 BERNARDO PLAZA CT
Practice Address - Street 2:STE 217
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2422
Practice Address - Country:US
Practice Address - Phone:858-484-2713
Practice Address - Fax:858-487-4741
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 12260103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY 12260OtherPHD
CACP12260Medicare ID - Type UnspecifiedMEDICARE
CAR59669Medicare UPIN