Provider Demographics
NPI:1477740496
Name:HARRIS, HOLLY (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 N EPWORTH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-2420
Mailing Address - Country:US
Mailing Address - Phone:618-516-2356
Mailing Address - Fax:618-824-6681
Practice Address - Street 1:106 EDWARDS ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IL
Practice Address - Zip Code:62448-1736
Practice Address - Country:US
Practice Address - Phone:618-783-4154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
IL1490137961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)