Provider Demographics
NPI:1669029682
Name:HOLLOWAY, CHUCKSON (PHD, MSW)
Entity Type:Individual
Prefix:DR
First Name:CHUCKSON
Middle Name:
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:PHD, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8934 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-1940
Mailing Address - Country:US
Mailing Address - Phone:414-841-1624
Mailing Address - Fax:414-231-9176
Practice Address - Street 1:6833 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-3900
Practice Address - Country:US
Practice Address - Phone:414-231-9176
Practice Address - Fax:414-231-9176
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor