Provider Demographics
NPI:1013914274
Name:HOLLIS, MARY LOU (EDD)
Entity Type:Individual
Prefix:DR
First Name:MARY LOU
Middle Name:
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5464 HOLIDAY TER
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2147
Mailing Address - Country:US
Mailing Address - Phone:269-372-1940
Mailing Address - Fax:269-349-5105
Practice Address - Street 1:5464 HOLIDAY TER
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2147
Practice Address - Country:US
Practice Address - Phone:269-372-1940
Practice Address - Fax:269-349-5105
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002452103TC0700X
MI4101005257106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOC945940OtherBCBSM
MI007039OtherVALUEOPTIONS
MI007039OtherVALUEOPTIONS
MIR67218Medicare UPIN