MEDICARE: BRUCE HOLLY JR. LCSWC

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	1041C0700X	Clinical Social Worker	10803	MD

General Provider Information

NPI Number	:	1396000972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE HOLLY JR. LCSWC

Provider Business Mailing Address
First Line	:	3 S FREDERICK ST
Second Line	:	SUITE 802
City	:	BALTIMORE
State	:	MD
Zip	:	21202-4034
Country	:	US
Telephone Number	:	410-327-4650
Fax Number	:	410-327-6825

Provider Business Practice Location Address
First Line	:	3 S FREDERICK ST
Second Line	:	SUITE 802
City	:	BALTIMORE
State	:	MD
Zip	:	21202-4034
Country	:	US
Telephone Number	:	410-327-4650
Fax Number	:	410-327-6825

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

Provider Enumeration Date	:	07/10/2012
Last Update Date	:	07/10/2012

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