Healthcare Provider Details

I. General information

NPI: 1992210934
Provider Name (Legal Business Name): HOLLY LYNN CONWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 12/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 W WASHINGTON BLVD
CHICAGO IL
60612-2055
US

IV. Provider business mailing address

10510 S SEELEY AVE
CHICAGO IL
60643-2633
US

V. Phone/Fax

Practice location:
  • Phone: 773-534-6640
  • Fax:
Mailing address:
  • Phone: 773-239-0305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: