Provider Demographics
NPI:1912414079
Name:HOLLIMAN, MAGGIE CLARE (EDS)
Entity type:Individual
Prefix:MS
First Name:MAGGIE
Middle Name:CLARE
Last Name:HOLLIMAN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4880 BRAMBLETON AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-4152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5937 COVE RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-2403
Practice Address - Country:US
Practice Address - Phone:540-562-3900
Practice Address - Fax:540-772-2195
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0813000391Medicaid