MEDICARE: HOLLY WAIDE

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	:	1811508575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY WAIDE

Provider Business Mailing Address
First Line	:	1056 HAYGOOD ESTATE LN
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-5558
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1064 LASKIN RD STE 14C
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-6337
Country	:	US
Telephone Number	:	757-233-1500
Fax Number	:

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

Provider Enumeration Date	:	08/14/2020
Last Update Date	:	08/14/2020

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Directions to “ HOLLY WAIDE ” Practice Location

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