Healthcare Provider Details

I. General information

NPI: 1326680794
Provider Name (Legal Business Name): DOROTHY LYNN HOLIDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 ALICE ST
MODESTO CA
95350-5905
US

IV. Provider business mailing address

1100 KANSAS AVE
MODESTO CA
95351-1596
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-3132
  • Fax:
Mailing address:
  • Phone: 209-579-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: