Healthcare Provider Details

I. General information

NPI: 1477740496
Provider Name (Legal Business Name): HOLLY HARRIS MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 EDWARDS ST
NEWTON IL
62448-1736
US

IV. Provider business mailing address

708 N EPWORTH ST
FAIRFIELD IL
62837-2420
US

V. Phone/Fax

Practice location:
  • Phone: 618-783-4154
  • Fax:
Mailing address:
  • Phone: 618-516-2356
  • Fax: 618-824-6681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149013796
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: