Provider Demographics
NPI:1982090924
Name:ANDERSON, HOLLEY (MSW,BA)
Entity Type:Individual
Prefix:
First Name:HOLLEY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MSW,BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E MAIN ST
Mailing Address - Street 2:4TH FLOOR ADMINISTRATION
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-574-9000
Mailing Address - Fax:203-574-9006
Practice Address - Street 1:141 E MAIN ST
Practice Address - Street 2:3RD FLOOR HOME BASED SERVICES
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-2310
Practice Address - Country:US
Practice Address - Phone:203-575-0466
Practice Address - Fax:203-575-1817
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1933104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT13606722OtherCAQH
CTPENDINGOtherHP MEDICAID
CT13606722OtherCAQH
CT13606722OtherCAQH
CTNOT ELIGIBLEMedicare PIN
CT060669107OtherUBH OXFORD HEALTH/LIBERTY/FREEDOM WELLMORE GRP/FACILITY
CT060669107OtherANTHEM BCBS OF CT WELLMORE GRP/FACILITY
CT060669107OtherUBH- UNITED HEALTHCARE WELLMORE GRP/FACILITY
CTD339209-WATERBURY141OtherVALUE OPTIONS
CT060669107OtherUBH-UNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITY
CTPENDINGOtherAETNA BEHAVIORAL HEALTH
CT060669107OtherHEALTHYCT WELLMORE GRP/FACILITY
CTPENDINGOtherCIGNA BEHAVIORAL HEALTH
CTNOT ELIGIBLEOtherMHN MANAGED HEALTH NETWORK