Provider Demographics
NPI:1912555095
Name:ELLIS, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:ELLIS
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 1:711 BERRY ST
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-2401
Mailing Address - Country:US
Mailing Address - Phone:571-730-7808
Mailing Address - Fax:
Practice Address - Street 1:107 CARPENTER DR STE 210
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-4468
Practice Address - Country:US
Practice Address - Phone:703-297-4368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-31
Last Update Date:2019-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004210103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical