Healthcare Provider Details

I. General information

NPI: 1275489833
Provider Name (Legal Business Name): DANELL HOLLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2026
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 S 38TH ST
SAN DIEGO CA
92113-3210
US

IV. Provider business mailing address

1127 S 38TH ST
SAN DIEGO CA
92113-3210
US

V. Phone/Fax

Practice location:
  • Phone: 619-262-4002
  • Fax: 619-264-2864
Mailing address:
  • Phone: 619-262-4002
  • Fax: 619-264-2864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number23905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: