Provider Demographics
NPI:1700878550
Name:ILFELD, HOLLY (PHD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:
Last Name:ILFELD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 LEAD HILL BLVD
Mailing Address - Street 2:STE. 110
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2941
Mailing Address - Country:US
Mailing Address - Phone:916-481-4585
Mailing Address - Fax:916-786-3080
Practice Address - Street 1:1380 LEAD HILL BLVD
Practice Address - Street 2:STE. 110
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2941
Practice Address - Country:US
Practice Address - Phone:916-481-4585
Practice Address - Fax:916-786-3080
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13211103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP61067Medicare UPIN
CA0PL132110Medicare ID - Type Unspecified