Provider Demographics
NPI:1306461900
Name:DICKENS, HOLLY ANN (RBT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:DICKENS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 ELMA G MILES PKWY
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4515
Mailing Address - Country:US
Mailing Address - Phone:912-294-4055
Mailing Address - Fax:866-467-4321
Practice Address - Street 1:938 ELMA G MILES PKWY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4515
Practice Address - Country:US
Practice Address - Phone:912-294-4055
Practice Address - Fax:866-467-4321
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20-122608106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA81-3839336OtherEMPLOYER EIN