Basic Information
| Provider Information | |||||||||
| NPI: | 1811480320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE SAMBOURG | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 829 HALBERT ST | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721042607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013324400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 MAIN ST STE V | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719134964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013218200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2018 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 8308-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.