Provider Demographics
NPI:1194741157
Name:LEFAVOUR, HOLLI A (PSYD)
Entity type:Individual
Prefix:
First Name:HOLLI
Middle Name:A
Last Name:LEFAVOUR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 A AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5036
Mailing Address - Country:US
Mailing Address - Phone:319-368-5892
Mailing Address - Fax:319-369-7812
Practice Address - Street 1:1026 A AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5036
Practice Address - Country:US
Practice Address - Phone:319-368-5892
Practice Address - Fax:319-369-7812
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001046103TC0700X
IL071006600103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807269000Medicaid
ID807269000Medicaid