Basic Information
| Provider Information | |||||||||
| NPI: | 1386150902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLAND | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | BEAVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150090457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246604159 | ||||||||
| FaxNumber: | 7246604233 | ||||||||
| Practice Location | |||||||||
| Address1: | 3471 OHIO RIVER ROAD | ||||||||
| Address2: | |||||||||
| City: | POINT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048125965 | ||||||||
| FaxNumber: | 3048125961 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2017 | ||||||||
| LastUpdateDate: | 12/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | CP00943198 | WV | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | CP00943198 | 01 | WV | WV STATE | OTHER |