Provider Demographics
NPI:1750975546
Name:GLICK, HOLLY MARIAH (LMSW)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:MARIAH
Last Name:GLICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1248 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6147
Mailing Address - Country:US
Mailing Address - Phone:208-542-1026
Mailing Address - Fax:
Practice Address - Street 1:1248 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6147
Practice Address - Country:US
Practice Address - Phone:208-542-1026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ID7261576104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00000Medicaid