Healthcare Provider Details

I. General information

NPI: 1629941679
Provider Name (Legal Business Name): HOLLY DYRUD LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2025
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1527 MADISON ST
FREDONIA KS
66736-1751
US

IV. Provider business mailing address

PO BOX 579
FREDONIA KS
66736-0579
US

V. Phone/Fax

Practice location:
  • Phone: 620-378-2121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW14350
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: