Healthcare Provider Details

I. General information

NPI: 1952805830
Provider Name (Legal Business Name): MARK LEONARD HOLLOWAY LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 BALDWIN ST
JENISON MI
49428-8912
US

IV. Provider business mailing address

1675 BALDWIN ST
JENISON MI
49428-8912
US

V. Phone/Fax

Practice location:
  • Phone: 616-426-9034
  • Fax:
Mailing address:
  • Phone: 616-426-9034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401016504
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: