Provider Demographics
NPI:1841725504
Name:ANDERSON, HOLLY (LCSW)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E 22ND ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6159
Mailing Address - Country:US
Mailing Address - Phone:417-291-8612
Mailing Address - Fax:
Practice Address - Street 1:1 E 22ND ST
Practice Address - Street 2:SUITE 310
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6159
Practice Address - Country:US
Practice Address - Phone:417-291-8612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.018939171M00000X
IL1490189391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1041C0700XMedicaid