Healthcare Provider Details

I. General information

NPI: 1831677152
Provider Name (Legal Business Name): HOLLY QUEEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 N MERIDIAN RD
YOUNGSTOWN OH
44509-1227
US

IV. Provider business mailing address

527 N MERIDIAN RD
YOUNGSTOWN OH
44509-1227
US

V. Phone/Fax

Practice location:
  • Phone: 330-797-0070
  • Fax:
Mailing address:
  • Phone: 330-797-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1801418
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: