=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780008565
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY ALLEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2014
-----------------------------------------------------
Last Update Date | 02/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 PALM AVE SUITE A
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92154-1011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-429-4117
-----------------------------------------------------
Fax | 619-429-4166
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 PALM AVE SUITE A
-----------------------------------------------------
City | IMPERIAL BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-429-4117
-----------------------------------------------------
Fax | 619-429-4166
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 143739
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------