Provider Demographics
NPI:1972746402
Name:HOLLAND, RUSSELL C (CAC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:C
Last Name:HOLLAND
Suffix:
Gender:M
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1067
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25402-1067
Mailing Address - Country:US
Mailing Address - Phone:304-263-7023
Mailing Address - Fax:304-264-0508
Practice Address - Street 1:99 TAVERN RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2890
Practice Address - Country:US
Practice Address - Phone:304-263-7023
Practice Address - Fax:304-264-0508
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV08-106101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)