Provider Demographics
NPI:1972273324
Name:STROUD, HOLLY (MED, BCBA,)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:STROUD
Suffix:
Gender:F
Credentials:MED, BCBA,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17441 UPPER PLEASANT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-9204
Mailing Address - Country:US
Mailing Address - Phone:208-407-4934
Mailing Address - Fax:
Practice Address - Street 1:17441 UPPER PLEASANT RIDGE RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-9204
Practice Address - Country:US
Practice Address - Phone:208-407-4934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician