Provider Demographics
NPI:1578077459
Name:HOLLISTER, BRANDON ALAN (PHD, LLC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:ALAN
Last Name:HOLLISTER
Suffix:
Gender:M
Credentials:PHD, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21410 MCCLELLAN CIR
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-6910
Mailing Address - Country:US
Mailing Address - Phone:402-460-7282
Mailing Address - Fax:
Practice Address - Street 1:11414 W CENTER RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4486
Practice Address - Country:US
Practice Address - Phone:402-333-8210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE943103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist