Basic Information
| Provider Information | |||||||||
| NPI: | 1588051700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELASCO | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 HAMLIN BLVD | ||||||||
| Address2: | |||||||||
| City: | INKSTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481412206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349414991 | ||||||||
| FaxNumber: | 3135650309 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 HAMLIN BLVD | ||||||||
| Address2: | |||||||||
| City: | INKSTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481412206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349414991 | ||||||||
| FaxNumber: | 3135650309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2015 | ||||||||
| LastUpdateDate: | 12/11/2018 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 104100000X | 6801103194 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.