Provider Demographics
NPI:1104589993
Name:WILSON, HOLLY W (RBT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:W
Last Name:WILSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 PULASKI AVE
Mailing Address - Street 2:
Mailing Address - City:PEARISBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24134-1220
Mailing Address - Country:US
Mailing Address - Phone:540-599-0717
Mailing Address - Fax:
Practice Address - Street 1:1004 PULASKI AVE
Practice Address - Street 2:
Practice Address - City:PEARISBURG
Practice Address - State:VA
Practice Address - Zip Code:24134-1220
Practice Address - Country:US
Practice Address - Phone:540-599-0717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-21-185132106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician