Healthcare Provider Details

I. General information

NPI: 1831715309
Provider Name (Legal Business Name): CHRISTINA HOLLIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E 17TH ST
AMMON ID
83406-6601
US

IV. Provider business mailing address

449 N 2500 E
SAINT ANTHONY ID
83445-5740
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-40033
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: