Provider Demographics
NPI:1780948521
Name:TICKLE, HOLLY S (MDIV,LMFT)
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:S
Last Name:TICKLE
Suffix:
Gender:F
Credentials:MDIV,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4845 SHORT ST
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1945
Mailing Address - Country:US
Mailing Address - Phone:770-271-8371
Mailing Address - Fax:
Practice Address - Street 1:3700 PLEASANT HILL RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3194
Practice Address - Country:US
Practice Address - Phone:404-784-6313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001179106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist