Provider Demographics
NPI:1629899315
Name:HOLLEY, RAINA
Entity type:Individual
Prefix:
First Name:RAINA
Middle Name:
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 TEHAMA CT
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3080
Mailing Address - Country:US
Mailing Address - Phone:863-254-8627
Mailing Address - Fax:
Practice Address - Street 1:1150 NW 72ND AVE STE 420
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-1921
Practice Address - Country:US
Practice Address - Phone:786-322-4846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-217799106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty