Provider Demographics
NPI:1285978510
Name:HOLLY, AMALIE
Entity type:Individual
Prefix:
First Name:AMALIE
Middle Name:
Last Name:HOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMALIE
Other - Middle Name:
Other - Last Name:HOLLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:5841 N WALNUT RD
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-9528
Mailing Address - Country:US
Mailing Address - Phone:877-828-8476
Mailing Address - Fax:209-260-0430
Practice Address - Street 1:528 14TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2503
Practice Address - Country:US
Practice Address - Phone:877-828-8476
Practice Address - Fax:209-260-0430
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-03-1320103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst