Provider Demographics
NPI:1801487913
Name:HOLLY, MICHAEL JR
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HOLLY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 E MOREHEAD ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2301
Mailing Address - Country:US
Mailing Address - Phone:919-576-7686
Mailing Address - Fax:
Practice Address - Street 1:3000 LATROBE DR STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5227
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:888-261-6694
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician