MEDICARE: MS. MELLODY RENAY HOLLOWAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1215111836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MELLODY RENAY HOLLOWAY

Provider Business Mailing Address
First Line	:	3630 N RANCHO DR STE 108
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-3111
Country	:	US
Telephone Number	:	702-979-9979
Fax Number	:

Provider Business Practice Location Address
First Line	:	3630 N RANCHO DR STE 108
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-3111
Country	:	US
Telephone Number	:	702-979-9979
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2007
Last Update Date	:	09/28/2021

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Directions to “ MS. MELLODY RENAY HOLLOWAY ” Practice Location

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