=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730391657
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA HOLLOWAY LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 02/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8608 UTICA AVE STE 205
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-770-0492
-----------------------------------------------------
Fax | 909-204-5202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 2504
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-770-0492
-----------------------------------------------------
Fax | 909-204-5202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC 39894
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------