Basic Information
| Provider Information | |||||||||
| NPI: | 1851780381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLIDAY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SUD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLLIDAY | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | SUD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1818 GILBRETH RD | ||||||||
| Address2: | 230 | ||||||||
| City: | BURLINGAME | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940101225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1818 GILBRETH RD | ||||||||
| Address2: | 230 | ||||||||
| City: | BURLINGAME | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940101225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503486603 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2015 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.