Provider Demographics
NPI:1386891570
Name:HOLLAND, JOHN ROBERT (CSWA/QMHP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:HOLLAND
Suffix:
Gender:M
Credentials:CSWA/QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3816
Mailing Address - Country:US
Mailing Address - Phone:503-842-8201
Mailing Address - Fax:503-815-1870
Practice Address - Street 1:906 MAIN AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3816
Practice Address - Country:US
Practice Address - Phone:503-842-8201
Practice Address - Fax:503-815-1870
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X, 101YM0800X
ORA4563104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500704226Medicaid