=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245586999
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY JEAN WALLRAFF LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2012
-----------------------------------------------------
Last Update Date | 07/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1612 WILLIAMS DR
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78628-3660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-574-0014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4903 HEATHER LN APT A
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76549-4878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-574-0014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 56842
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------