Provider Demographics
NPI:1790393973
Name:HOLLADAY, KELLEY (PHD, LMHC, LPCC, NCC)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:HOLLADAY
Suffix:
Gender:F
Credentials:PHD, LMHC, LPCC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6711 PIEDRA QUEMADA RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-3490
Mailing Address - Country:US
Mailing Address - Phone:505-604-4120
Mailing Address - Fax:
Practice Address - Street 1:1782 PLANTATION OAKS DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-5010
Practice Address - Country:US
Practice Address - Phone:505-604-4120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12648101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty