Provider Demographics
NPI:1982663597
Name:LINEBACK, HOLLY H (CPCI)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:H
Last Name:LINEBACK
Suffix:
Gender:F
Credentials:CPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2977 S 1400 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3474
Mailing Address - Country:US
Mailing Address - Phone:801-486-4685
Mailing Address - Fax:
Practice Address - Street 1:8184 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-6477
Practice Address - Country:US
Practice Address - Phone:801-944-1666
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5072655-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health