Basic Information
| Provider Information | |||||||||
| NPI: | 1003293812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLAND | ||||||||
| FirstName: | DINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 HOPKINSVILLE ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423451124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703385777 | ||||||||
| FaxNumber: | 2703385765 | ||||||||
| Practice Location | |||||||||
| Address1: | 226 HOPKINSVILLE ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423451214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703773077 | ||||||||
| FaxNumber: | 2703773002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2015 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3678 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 31000458 | 05 | KY | MEDICAID |