Basic Information
| Provider Information | |||||||||
| NPI: | 1285933531 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLOWAY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2569 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982130569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252124224 | ||||||||
| FaxNumber: | 4252124299 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254935800 | ||||||||
| FaxNumber: | 4252124299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2011 | ||||||||
| LastUpdateDate: | 03/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.