Provider Demographics
NPI:1386253532
Name:HOLLIE, KELLY DORTHEA
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DORTHEA
Last Name:HOLLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S 500 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-2233
Mailing Address - Country:US
Mailing Address - Phone:801-359-2256
Mailing Address - Fax:
Practice Address - Street 1:660 S 200 E STE 250
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3846
Practice Address - Country:US
Practice Address - Phone:801-359-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7449886-3506104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker