Healthcare Provider Details

I. General information

NPI: 1396328795
Provider Name (Legal Business Name): BREANNA MARIE HOLLOWAY MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 07/31/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

740 BAYLOR AVE
BONITA CA
91902-4031
US

V. Phone/Fax

Practice location:
  • Phone: 619-212-0655
  • Fax:
Mailing address:
  • Phone: 619-212-0655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number36036
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: