Provider Demographics
NPI:1619260874
Name:HOLLY, ANNA GRACE (SAC-IT)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:GRACE
Last Name:HOLLY
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 N 17TH ST
Mailing Address - Street 2:APT. 304
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-3302
Mailing Address - Country:US
Mailing Address - Phone:920-450-0960
Mailing Address - Fax:
Practice Address - Street 1:600 W VIRGINIA ST
Practice Address - Street 2:SUITE 203
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-1500
Practice Address - Country:US
Practice Address - Phone:414-831-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16045-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)