Provider Demographics
NPI:1770502502
Name:HOLLEY, DARA (LCSW)
Entity Type:Individual
Prefix:
First Name:DARA
Middle Name:
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-1239
Mailing Address - Country:US
Mailing Address - Phone:727-327-7656
Mailing Address - Fax:727-388-1192
Practice Address - Street 1:4024 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1239
Practice Address - Country:US
Practice Address - Phone:727-327-7656
Practice Address - Fax:727-388-1192
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW61921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEY507ZOtherMEDICARE
FL761752600Medicaid
FLF00545OtherFLORIDA HEALTH PARTNERS