Healthcare Provider Details

I. General information

NPI: 1073172102
Provider Name (Legal Business Name): HOLLY DEANNE VAVLAS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3591 RESERVE COMMONS DR STE 100
MEDINA OH
44256-5334
US

IV. Provider business mailing address

PO BOX 844020
DALLAS TX
75284-4020
US

V. Phone/Fax

Practice location:
  • Phone: 216-450-1613
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2505093
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: