Provider Demographics
NPI:1669018933
Name:HOLLERAN, LORI J (PHD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:J
Last Name:HOLLERAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W CLARENDON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3422
Mailing Address - Country:US
Mailing Address - Phone:602-776-0776
Mailing Address - Fax:602-705-0567
Practice Address - Street 1:3522 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3903
Practice Address - Country:US
Practice Address - Phone:602-776-7676
Practice Address - Fax:602-776-3002
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-005099103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical