Provider Demographics
NPI:1801932900
Name:HARTSON-BOWYER, HOLLY (PHD)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:HARTSON-BOWYER
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 1:205 S WHITING ST STE 312
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-3632
Mailing Address - Country:US
Mailing Address - Phone:703-249-5160
Mailing Address - Fax:
Practice Address - Street 1:139 FERRUM DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7123
Practice Address - Country:US
Practice Address - Phone:703-249-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18658103T00000X
VA0810005581103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91660Medicare UPIN