Provider Demographics
NPI:1679642375
Name:HOLLAND, MICKIE (LPCC, LBSW)
Entity Type:Individual
Prefix:
First Name:MICKIE
Middle Name:
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:LPCC, LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-5529
Mailing Address - Country:US
Mailing Address - Phone:505-393-3168
Mailing Address - Fax:505-397-4659
Practice Address - Street 1:920 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-5529
Practice Address - Country:US
Practice Address - Phone:505-393-3168
Practice Address - Fax:505-397-4659
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM006101101YP2500X
NM280435103TS0200X
NMB0424104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46300Medicaid