Provider Demographics
NPI:1023610557
Name:HOLLOWAY, KRANEISHA RENEE (LAC)
Entity type:Individual
Prefix:
First Name:KRANEISHA
Middle Name:RENEE
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 N NAVADA ST
Mailing Address - Street 2:1213
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226
Mailing Address - Country:US
Mailing Address - Phone:480-487-9098
Mailing Address - Fax:
Practice Address - Street 1:4330 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-7004
Practice Address - Country:US
Practice Address - Phone:480-296-3546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC17711101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLAC17711OtherLAC