MEDICARE: ODYSSEY NICOLE HOLLOMAN

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	106E00000X	Assistant Behavior Analyst		MI

General Provider Information

NPI Number	:	1992652721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ODYSSEY NICOLE HOLLOMAN

Provider Business Mailing Address
First Line	:	1428 E ALCOTT ST
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49001-4345
Country	:	US
Telephone Number	:	859-755-6304
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 3 MILE RD NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49544-1685
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:

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

Provider Enumeration Date	:	03/11/2026
Last Update Date	:	03/11/2026

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