Healthcare Provider Details

I. General information

NPI: 1477739621
Provider Name (Legal Business Name): HOLLY ANN HOUSE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1094 CUDAHY PL STE 314
SAN DIEGO CA
92110-3924
US

IV. Provider business mailing address

1094 CUDAHY PL STE 314
SAN DIEGO CA
92110-3924
US

V. Phone/Fax

Practice location:
  • Phone: 619-276-8112
  • Fax: 619-276-8230
Mailing address:
  • Phone: 619-276-8112
  • Fax: 619-276-8230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 24153
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: