Provider Demographics
NPI:1841215696
Name:HOLLIS, MARTHA L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:L
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MARTY
Other - Middle Name:
Other - Last Name:HOLLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2486 HILLPOINT RD
Mailing Address - Street 2:
Mailing Address - City:MC FARLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53558
Mailing Address - Country:US
Mailing Address - Phone:608-838-3969
Mailing Address - Fax:
Practice Address - Street 1:2727 MARSHALL CT
Practice Address - Street 2:PSYCHIATRIC SERVICES
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705
Practice Address - Country:US
Practice Address - Phone:608-238-7354
Practice Address - Fax:608-238-7675
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5221231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39075500Medicaid
WI39075500Medicaid