Provider Demographics
NPI:1629341797
Name:HOLLAND, KATHRYN M (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:1001 W 10TH ST
Practice Address - Street 2:B2109
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2859
Practice Address - Country:US
Practice Address - Phone:317-630-2617
Practice Address - Fax:317-630-2587
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340016461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400066856Medicare PIN