Basic Information
Provider Information | |||||||||
NPI: | 1316427727 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLLADAY | ||||||||
FirstName: | KEELEE | ||||||||
MiddleName: | BRIELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RUSHING | ||||||||
OtherFirstName: | KEELEE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LMSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1707 LINWOOD DR STE G | ||||||||
Address2: |   | ||||||||
City: | PARAGOULD | ||||||||
State: | AR | ||||||||
PostalCode: | 724505365 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8706044455 | ||||||||
FaxNumber: | 8889772956 | ||||||||
Practice Location | |||||||||
Address1: | 1707 LINWOOD DR STE G | ||||||||
Address2: |   | ||||||||
City: | PARAGOULD | ||||||||
State: | AR | ||||||||
PostalCode: | 724505365 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8706044455 | ||||||||
FaxNumber: | 8897729568 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2018 | ||||||||
LastUpdateDate: | 08/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 8873-M | AR | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 104100000X | MSW008769 | GA | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 101YM0800X | 8873-M | AR | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 228135795 | 05 | AR |   | MEDICAID |