Provider Demographics
NPI:1760997795
Name:HOLLOWAY, RACHEL NICOLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:NICOLE
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12501 E HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2670
Mailing Address - Country:US
Mailing Address - Phone:618-315-4684
Mailing Address - Fax:
Practice Address - Street 1:623 S 34TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6203
Practice Address - Country:US
Practice Address - Phone:618-315-4684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146007236235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146007236Medicaid