Provider Demographics
NPI:1174703912
Name:HOUSTON, HOLLY OUIDA (PHD)
Entity type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:OUIDA
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 BRASSIE AVE
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1819
Mailing Address - Country:US
Mailing Address - Phone:708-957-7718
Mailing Address - Fax:708-957-7721
Practice Address - Street 1:18161 MORRIS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2108
Practice Address - Country:US
Practice Address - Phone:708-349-5433
Practice Address - Fax:708-349-5433
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2016-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004128103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCH6894OtherPTAN MEDICARE RAILROAD
ILCH6894OtherPTAN MEDICARE RAILROAD