Healthcare Provider Details

I. General information

NPI: 1093884975
Provider Name (Legal Business Name): LISA C HOLLABAUGH P.H.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N MAIN ST
ANNA IL
62906-1652
US

IV. Provider business mailing address

7929 OLD HIGHWAY 13
MURPHYSBORO IL
62966-6507
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-5161
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: