Provider Demographics
NPI:1730673518
Name:MCCORD, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:MCCORD
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 1:4432 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84310-6801
Mailing Address - Country:US
Mailing Address - Phone:678-761-5075
Mailing Address - Fax:
Practice Address - Street 1:3340 HARRISON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1271
Practice Address - Country:US
Practice Address - Phone:801-393-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1760788285Medicaid