Provider Demographics
NPI:1407404460
Name:HOLSONBACK, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:HOLSONBACK
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 1:120 MEGHAN LN
Mailing Address - Street 2:
Mailing Address - City:JUDSONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72081-9302
Mailing Address - Country:US
Mailing Address - Phone:866-729-4479
Mailing Address - Fax:
Practice Address - Street 1:120 MEGHAN LN
Practice Address - Street 2:
Practice Address - City:JUDSONIA
Practice Address - State:AR
Practice Address - Zip Code:72081-9302
Practice Address - Country:US
Practice Address - Phone:866-729-4479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1810149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional