Healthcare Provider Details

I. General information

NPI: 1285978510
Provider Name (Legal Business Name): AMALIE HOLLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMALIE HOLLY MA

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 14TH ST
MODESTO CA
95354-2503
US

IV. Provider business mailing address

5841 N WALNUT RD
TURLOCK CA
95382-9528
US

V. Phone/Fax

Practice location:
  • Phone: 877-828-8476
  • Fax: 209-260-0430
Mailing address:
  • Phone: 877-828-8476
  • Fax: 209-260-0430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-03-1320
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: