Provider Demographics
NPI:1194896761
Name:ROTHENBUSH, HOLLY NICOLE (LMFT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:NICOLE
Last Name:ROTHENBUSH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 SAINT JOE CENTER RD STE 23
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5000
Mailing Address - Country:US
Mailing Address - Phone:260-484-5599
Mailing Address - Fax:260-484-5664
Practice Address - Street 1:1910 SAINT JOE CENTER RD STE 23
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5000
Practice Address - Country:US
Practice Address - Phone:260-484-5599
Practice Address - Fax:260-484-5664
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001605A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health