Provider Demographics
NPI:1306445424
Name:VANDOREN, HOLLY MARTIN (MS)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:MARTIN
Last Name:VANDOREN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:498 LAKE ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:MEADOW VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95722-9569
Mailing Address - Country:US
Mailing Address - Phone:530-392-2109
Mailing Address - Fax:
Practice Address - Street 1:11484 B AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2603
Practice Address - Country:US
Practice Address - Phone:530-886-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool