Provider Demographics
NPI:1588393193
Name:HOLLOWAY, MONIET
Entity type:Individual
Prefix:
First Name:MONIET
Middle Name:
Last Name:HOLLOWAY
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 1:19509 LAKE PARK DR
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1560
Mailing Address - Country:US
Mailing Address - Phone:708-712-2404
Mailing Address - Fax:
Practice Address - Street 1:19509 LAKE PARK DR
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60411-1560
Practice Address - Country:US
Practice Address - Phone:708-949-6438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker