Provider Demographics
NPI:1285787317
Name:HOLLENBECK, BURT GEORGE JR (PHD)
Entity type:Individual
Prefix:DR
First Name:BURT
Middle Name:GEORGE
Last Name:HOLLENBECK
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 ROXBURY ST
Mailing Address - Street 2:SUITE 302 A
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-8801
Mailing Address - Country:US
Mailing Address - Phone:603-357-5600
Mailing Address - Fax:603-357-5600
Practice Address - Street 1:103 ROXBURY ST
Practice Address - Street 2:SUITE 302 A
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-8801
Practice Address - Country:US
Practice Address - Phone:603-357-5600
Practice Address - Fax:603-357-5600
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH442103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30420988Medicaid