Provider Demographics
NPI:1912429481
Name:HEATH, HOLLY ANN (LPCA)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:ANN
Last Name:HEATH
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 LAWNDALE DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4015
Mailing Address - Country:US
Mailing Address - Phone:724-968-8264
Mailing Address - Fax:
Practice Address - Street 1:1834 WAKE FOREST RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27109-6000
Practice Address - Country:US
Practice Address - Phone:724-968-8264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12464101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health