Provider Demographics
NPI:1639791106
Name:HOLLY HEAVEN
Entity Type:Organization
Organization Name:HOLLY HEAVEN
Other - Org Name:ANOTHER WAY COUNSELING SERVICE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:203-545-1582
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-0011
Mailing Address - Country:US
Mailing Address - Phone:203-545-1582
Mailing Address - Fax:
Practice Address - Street 1:1057 BROAD ST STE 304
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4219
Practice Address - Country:US
Practice Address - Phone:203-545-1582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-07
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty