Healthcare Provider Details

I. General information

NPI: 1568944478
Provider Name (Legal Business Name): HOLLY MARIE MOORE ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HOLLY MARIE HOAGLAND

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WOOD ST
EUREKA CA
95501-4413
US

IV. Provider business mailing address

1025 COUSINS ST APT D
EUREKA CA
95501-5623
US

V. Phone/Fax

Practice location:
  • Phone: 707-268-2990
  • Fax:
Mailing address:
  • Phone: 916-613-3321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number85423
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number85423
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: