Healthcare Provider Details

I. General information

NPI: 1649948407
Provider Name (Legal Business Name): WALTER SHERARD HOLLOWAY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2021
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 OLDE HICKORY CIR
BONAIRE GA
31005-3496
US

IV. Provider business mailing address

1745 PHOENIX BLVD STE 240
ATLANTA GA
30349-5534
US

V. Phone/Fax

Practice location:
  • Phone: 478-225-2508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC007848
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: