Provider Demographics
NPI:1316084494
Name:HOLLEY, IDA MARIE (LMHC)
Entity type:Individual
Prefix:MS
First Name:IDA
Middle Name:MARIE
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1457
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32067-1457
Mailing Address - Country:US
Mailing Address - Phone:904-278-8722
Mailing Address - Fax:904-278-4880
Practice Address - Street 1:1532 KINGSLEY AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4538
Practice Address - Country:US
Practice Address - Phone:904-278-8722
Practice Address - Fax:904-278-4880
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6257101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health