Provider Demographics
NPI:1780008565
Name:ALLEN, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:ALLEN
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 1:1515 PALM AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92154
Mailing Address - Country:US
Mailing Address - Phone:619-429-4117
Mailing Address - Fax:619-429-4166
Practice Address - Street 1:1515 PALM AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-1011
Practice Address - Country:US
Practice Address - Phone:619-429-4117
Practice Address - Fax:619-429-4166
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA143739101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)