1093270613 NPI number — HOLLY SMITH RAKESTRAW LPC, NCC, NCSC

Table of content: HOLLY SMITH RAKESTRAW LPC, NCC, NCSC (NPI 1093270613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093270613 NPI number — HOLLY SMITH RAKESTRAW LPC, NCC, NCSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAKESTRAW
Provider First Name:
HOLLY
Provider Middle Name:
SMITH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, NCC, NCSC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093270613
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 MEGS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALTILLO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38866-7940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-213-4676
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
813 VARSITY DR STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUPELO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38801-4694
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-840-2005
Provider Business Practice Location Address Fax Number:
662-840-2107
Provider Enumeration Date:
02/07/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  975 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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