Provider Demographics
NPI:1215793849
Name:HOLDER, SHELLEY
Entity type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:
Last Name:HOLDER
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 1:1655 FLATBUSH AVE APT B1804
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-6911
Mailing Address - Country:US
Mailing Address - Phone:347-267-2215
Mailing Address - Fax:
Practice Address - Street 1:960 ELTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-5418
Practice Address - Country:US
Practice Address - Phone:347-267-2215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076785-01101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor