Provider Demographics
NPI:1477681930
Name:HOLLISTER, CHUCK J
Entity Type:Individual
Prefix:DR
First Name:CHUCK
Middle Name:J
Last Name:HOLLISTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 W PORTLAND ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-1911
Mailing Address - Country:US
Mailing Address - Phone:417-832-0601
Mailing Address - Fax:
Practice Address - Street 1:632 W PORTLAND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-1911
Practice Address - Country:US
Practice Address - Phone:417-832-0601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01790103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist