Healthcare Provider Details

I. General information

NPI: 1750070835
Provider Name (Legal Business Name): CHRISTOPHER BRYAN HOLLOWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 ISABEL ST
SKOKIE IL
60076-3312
US

IV. Provider business mailing address

3825 ISABEL ST
SKOKIE IL
60076-3312
US

V. Phone/Fax

Practice location:
  • Phone: 224-420-2704
  • Fax:
Mailing address:
  • Phone: 224-420-2704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180015143
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180015143
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: