Provider Demographics
NPI:1619475092
Name:HOLLIS, CHASTITY HELENA
Entity Type:Individual
Prefix:
First Name:CHASTITY
Middle Name:HELENA
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5494 PONY EXPRESS TR
Mailing Address - Street 2:
Mailing Address - City:CAMINO
Mailing Address - State:CA
Mailing Address - Zip Code:95709
Mailing Address - Country:US
Mailing Address - Phone:530-644-3758
Mailing Address - Fax:
Practice Address - Street 1:5494 PONY EXPRESS TR
Practice Address - Street 2:
Practice Address - City:CAMINO
Practice Address - State:CA
Practice Address - Zip Code:95709
Practice Address - Country:US
Practice Address - Phone:530-644-3758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)