Provider Demographics
NPI:1730563222
Name:HOLLENHORST, DIANA (BAED, ECE P-3)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:HOLLENHORST
Suffix:
Gender:F
Credentials:BAED, ECE P-3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:900 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4168
Practice Address - Country:US
Practice Address - Phone:425-258-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60490899103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2046882Medicaid