MEDICARE: MARY NANCY HOLLIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1639761323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY NANCY HOLLIS

Provider Business Mailing Address
First Line	:	117 CHURCH RD
Second Line	:
City	:	WINNETKA
State	:	IL
Zip	:	60093-3903
Country	:	US
Telephone Number	:	415-624-5796
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 CHURCH RD
Second Line	:
City	:	WINNETKA
State	:	IL
Zip	:	60093-3903
Country	:	US
Telephone Number	:	415-624-5796
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2021
Last Update Date	:	02/04/2021

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