Provider Demographics
NPI:1487116521
Name:VINCENT A HOLLISTER LLC
Entity type:Organization
Organization Name:VINCENT A HOLLISTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW- CT, LICSW-MA
Authorized Official - Phone:860-716-5998
Mailing Address - Street 1:99 HIGHLAND VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071-1557
Mailing Address - Country:US
Mailing Address - Phone:860-716-5998
Mailing Address - Fax:
Practice Address - Street 1:41 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2545
Practice Address - Country:US
Practice Address - Phone:860-716-5998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008057276Medicaid