Healthcare Provider Details

I. General information

NPI: 1235341801
Provider Name (Legal Business Name): CODY STONEWALL HOLLIST PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 N LEXINGTON PL
CENTERTON AR
72719-9539
US

IV. Provider business mailing address

1570 N LEXINGTON PL
CENTERTON AR
72719-9539
US

V. Phone/Fax

Practice location:
  • Phone: 402-202-0506
  • Fax:
Mailing address:
  • Phone: 402-202-0506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number115
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: