Provider Demographics
NPI:1710332580
Name:SKRETTA, HOLLY ALICE (MFT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ALICE
Last Name:SKRETTA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-1312
Mailing Address - Country:US
Mailing Address - Phone:920-728-3609
Mailing Address - Fax:
Practice Address - Street 1:415 N STEVENS AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-1312
Practice Address - Country:US
Practice Address - Phone:920-728-3609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI513-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist