Provider Demographics
NPI:1932619947
Name:SMITH, HOLLY (BCABA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:FAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2189 MEADOW GRASS DR
Mailing Address - Street 2:
Mailing Address - City:PACIFIC
Mailing Address - State:MO
Mailing Address - Zip Code:63069-3652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16375 PIERSIDE LN
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1600
Practice Address - Country:US
Practice Address - Phone:636-405-2701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst