Provider Demographics
NPI:1215111836
Name:HOLLOWAY, MELLODY RENAY
Entity type:Individual
Prefix:MS
First Name:MELLODY
Middle Name:RENAY
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 N RANCHO DR STE 108
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3111
Mailing Address - Country:US
Mailing Address - Phone:702-979-9979
Mailing Address - Fax:
Practice Address - Street 1:3630 N RANCHO DR STE 108
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3111
Practice Address - Country:US
Practice Address - Phone:702-979-9979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker