Provider Demographics
NPI:1922368067
Name:HOLLOWAY, PETRINA
Entity Type:Individual
Prefix:
First Name:PETRINA
Middle Name:
Last Name:HOLLOWAY
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 1:551 N 28TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-6139
Mailing Address - Country:US
Mailing Address - Phone:918-794-0197
Mailing Address - Fax:
Practice Address - Street 1:2625 N PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-2512
Practice Address - Country:US
Practice Address - Phone:918-794-0196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor