Provider Demographics
NPI:1558595397
Name:HOLLEY, MATTHEW GREGORY (MA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:GREGORY
Last Name:HOLLEY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1963 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2394
Mailing Address - Country:US
Mailing Address - Phone:619-233-3432
Mailing Address - Fax:619-233-7022
Practice Address - Street 1:1963 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2394
Practice Address - Country:US
Practice Address - Phone:619-233-3432
Practice Address - Fax:619-233-7022
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF60090106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist