Provider Demographics
NPI:1336521970
Name:HOLLINS, DEIDERE (LPC-S)
Entity Type:Individual
Prefix:
First Name:DEIDERE
Middle Name:
Last Name:HOLLINS
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 MAGNOLIA WAY
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-3366
Mailing Address - Country:US
Mailing Address - Phone:601-573-9849
Mailing Address - Fax:
Practice Address - Street 1:3450 HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-7201
Practice Address - Country:US
Practice Address - Phone:601-321-2400
Practice Address - Fax:601-985-5174
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1628101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018209Medicaid