Healthcare Provider Details

I. General information

NPI: 1265629430
Provider Name (Legal Business Name): MARK HOLLAND PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 KING BLVD SUITE 313
CASPER WY
82604-3166
US

IV. Provider business mailing address

2435 KING BLVD SUITE 313
CASPER WY
82604-3166
US

V. Phone/Fax

Practice location:
  • Phone: 307-462-4876
  • Fax: 307-337-3492
Mailing address:
  • Phone: 307-462-4876
  • Fax: 307-337-3492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number544
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: