Provider Demographics
NPI:1447719489
Name:HOLLEY, SAMUEL LAWRENCE
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LAWRENCE
Last Name:HOLLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 N COLLEGE RD
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3484
Practice Address - Country:US
Practice Address - Phone:208-814-9100
Practice Address - Fax:208-814-9903
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-20132084P0800X
WACG61210477101Y00000X
WAOP614061642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101Y00000XBehavioral Health & Social Service ProvidersCounselor