Provider Demographics
NPI:1821438250
Name:HOLLOWAY, BETH MUMFORD
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:MUMFORD
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:BETH
Other - Middle Name:COLLEEN
Other - Last Name:HOLLOWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:124 DOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-9774
Mailing Address - Country:US
Mailing Address - Phone:919-810-2689
Mailing Address - Fax:
Practice Address - Street 1:308 W MILLBROOK RD
Practice Address - Street 2:SUITE A
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4574
Practice Address - Country:US
Practice Address - Phone:919-848-2100
Practice Address - Fax:919-848-2009
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-29
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA9790101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health