Provider Demographics
NPI:1790022176
Name:VESTAL, HOLLY ANN (MSW)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:VESTAL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 W MICHIGAN AVE
Mailing Address - Street 2:211 AND 212
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-5892
Mailing Address - Country:US
Mailing Address - Phone:269-370-3038
Mailing Address - Fax:
Practice Address - Street 1:4200 W MICHIGAN AVE
Practice Address - Street 2:211 AND 212
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-5892
Practice Address - Country:US
Practice Address - Phone:269-370-3038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-06
Last Update Date:2013-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010467541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical