Provider Demographics
NPI:1689804908
Name:HOLLINGSWORTH, JOSHUA KERMIT (MA)
Entity type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:KERMIT
Last Name:HOLLINGSWORTH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5703 BEDFORD LOOP E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-7534
Mailing Address - Country:US
Mailing Address - Phone:530-220-3643
Mailing Address - Fax:
Practice Address - Street 1:5740 GETWELL RD STE D
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6346
Practice Address - Country:US
Practice Address - Phone:601-790-0583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
MS2921101YM0800X
CA60105101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7184OtherMEDICAL
CA7368OtherMEDICAL
CA7708OtherMEDICAL
MS2921OtherMEDICAL
CA7667OtherMEDICAL