Basic Information
| Provider Information | |||||||||
| NPI: | 1144409798 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLIS | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | MAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4133 FOX BRUSH DR | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308094882 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 FREEDOM WAY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309046258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067330188 | ||||||||
| FaxNumber: | 7068233952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC004721 | GA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 104100000X | MSW004452 | GA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.