Provider Demographics
NPI:1396779724
Name:HOLLIDAY, PATRICIA B (PHD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:B
Last Name:HOLLIDAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:BOYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:104 CEDAR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2100
Mailing Address - Country:US
Mailing Address - Phone:601-648-0506
Mailing Address - Fax:
Practice Address - Street 1:248 E CAPITOL ST
Practice Address - Street 2:840 TRUST MARK BLDG
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-2503
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:866-341-7509
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS46748103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00364890OtherRR MCARE W PARADIGM
MS06476266Medicaid
MSP00364890OtherRR MCARE W PARADIGM