Provider Demographics
NPI:1659694990
Name:HOLLY, ROGER HUGH (MS)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:HUGH
Last Name:HOLLY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9690 FALCONER WAY
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-3026
Mailing Address - Country:US
Mailing Address - Phone:239-275-3222
Mailing Address - Fax:
Practice Address - Street 1:2789 ORTIZ AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7806
Practice Address - Country:US
Practice Address - Phone:239-275-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist