Provider Demographics
NPI:1487316311
Name:HOLLISTER, NICOLE RYAN (LMSW)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:RYAN
Last Name:HOLLISTER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5584 S FORT APACHE RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-7657
Mailing Address - Country:US
Mailing Address - Phone:702-296-1222
Mailing Address - Fax:
Practice Address - Street 1:5584 S FORT APACHE RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-7657
Practice Address - Country:US
Practice Address - Phone:702-296-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9588M1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1790253060Medicaid