=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316427727
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEELEE BRIELLE HOLLADAY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2018
-----------------------------------------------------
Last Update Date | 01/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 ELLIS DR
-----------------------------------------------------
City | BROOKLAND
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72417-8023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-543-7499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1707 LINWOOD DR STE G
-----------------------------------------------------
City | PARAGOULD
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72450-5365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-604-4455
-----------------------------------------------------
Fax | 888-977-2956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | MSW008769
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 8873-C
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 8873-M
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 8873-M
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------