Provider Demographics
NPI:1518465079
Name:HOLLY PSYCHIATRIC CLINIC PLLC
Entity Type:Organization
Organization Name:HOLLY PSYCHIATRIC CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:QUINTANILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-993-4835
Mailing Address - Street 1:4444 CORONA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-4300
Mailing Address - Country:US
Mailing Address - Phone:361-993-4835
Mailing Address - Fax:361-993-7043
Practice Address - Street 1:4444 CORONA DR STE 150
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4300
Practice Address - Country:US
Practice Address - Phone:361-993-4835
Practice Address - Fax:361-993-7043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-30
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX451455601Medicaid
TX2B0918OtherMEDICARE