Provider Demographics
NPI:1265960934
Name:HOLLIS, CAPRICIA RENEE
Entity type:Individual
Prefix:
First Name:CAPRICIA
Middle Name:RENEE
Last Name:HOLLIS
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 1:2901 CAMPUS RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-2153
Mailing Address - Country:US
Mailing Address - Phone:646-659-2120
Mailing Address - Fax:
Practice Address - Street 1:2901 CAMPUS RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-2153
Practice Address - Country:US
Practice Address - Phone:646-659-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090710-1104100000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY252Y00000XMedicaid