Healthcare Provider Details

I. General information

NPI: 1295148724
Provider Name (Legal Business Name): HOLLY LYN PROCKO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32100 TELEGRAPH RD
BINGHAM FARMS MI
48025-2452
US

IV. Provider business mailing address

32100 TELEGRAPH RD
BINGHAM FARMS MI
48025-2452
US

V. Phone/Fax

Practice location:
  • Phone: 862-377-9525
  • Fax:
Mailing address:
  • Phone: 862-377-9525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-13-12854
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: