Provider Demographics
NPI:1568944478
Name:MOORE, HOLLY MARIE (ASW)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:MARIE
Other - Last Name:HOAGLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1025 COUSINS ST APT D
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-5623
Mailing Address - Country:US
Mailing Address - Phone:916-613-3321
Mailing Address - Fax:
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4413
Practice Address - Country:US
Practice Address - Phone:707-268-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85423106H00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty