Provider Demographics
NPI:1700900024
Name:PEDERSEN, HOLLY LYNN (MFT, PHD)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:LYNN
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4226 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2723
Mailing Address - Country:US
Mailing Address - Phone:323-719-0959
Mailing Address - Fax:310-928-0368
Practice Address - Street 1:3737 MARTIN LUTHER KING JR BLVD STE 612
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3537
Practice Address - Country:US
Practice Address - Phone:310-603-2795
Practice Address - Fax:310-928-0368
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37441106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist