Healthcare Provider Details

I. General information

NPI: 1093074205
Provider Name (Legal Business Name): KASEY S HOLYFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 CANTERBURY DR STE C
VALDOSTA GA
31602-0503
US

IV. Provider business mailing address

1801 CANTERBURY DR STE C
VALDOSTA GA
31602-0503
US

V. Phone/Fax

Practice location:
  • Phone: 229-244-2030
  • Fax:
Mailing address:
  • Phone: 229-427-0057
  • Fax: 215-258-8588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: