Healthcare Provider Details

I. General information

NPI: 1255989265
Provider Name (Legal Business Name): HOLLY ANN SAMEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY ANN MAGEE

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 WILLAGILLESPIE RD
EUGENE OR
97401
US

IV. Provider business mailing address

129 GREEN LN
EUGENE OR
97404-2492
US

V. Phone/Fax

Practice location:
  • Phone: 541-666-3652
  • Fax:
Mailing address:
  • Phone: 541-852-7946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberB172312
License Number StateOR

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: