Provider Demographics
NPI:1699364125
Name:WIGHT, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:WIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:MIO
Mailing Address - State:MI
Mailing Address - Zip Code:48647-0148
Mailing Address - Country:US
Mailing Address - Phone:989-826-3208
Mailing Address - Fax:
Practice Address - Street 1:42 N MOUNT TOM RD
Practice Address - Street 2:
Practice Address - City:MIO
Practice Address - State:MI
Practice Address - Zip Code:48647-8739
Practice Address - Country:US
Practice Address - Phone:989-387-3992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker