Healthcare Provider Details

I. General information

NPI: 1871606988
Provider Name (Legal Business Name): HOLLY J DEVORE MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 E SAN RAFAEL ST
COLORADO SPGS CO
80903
US

IV. Provider business mailing address

317 E SAN RAFAEL ST
COLORADO SPGS CO
80903
US

V. Phone/Fax

Practice location:
  • Phone: 719-633-4845
  • Fax:
Mailing address:
  • Phone: 719-633-4845
  • Fax: 719-634-2563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number035
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: