Provider Demographics
NPI:1437713492
Name:CONKLIN, HOLLY LYN (CDC-A, CIP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LYN
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:CDC-A, CIP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:L
Other - Last Name:CONKLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CDC-A, CIP
Mailing Address - Street 1:123 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-1707
Mailing Address - Country:US
Mailing Address - Phone:918-500-2570
Mailing Address - Fax:419-771-1051
Practice Address - Street 1:123 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-1707
Practice Address - Country:US
Practice Address - Phone:918-500-2570
Practice Address - Fax:419-771-1051
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.169820101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH427664Medicaid