Provider Demographics
NPI:1003052911
Name:HOLTZ, NICOLE (COTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HOLTZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 JACKSON STREET
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1520
Mailing Address - Country:US
Mailing Address - Phone:608-873-6448
Mailing Address - Fax:
Practice Address - Street 1:814 JACKSON STREET
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1520
Practice Address - Country:US
Practice Address - Phone:608-873-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4658027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant