Provider Demographics
NPI:1033454186
Name:HOLLIS, MELISSA LYNN (COTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:HOLLIS
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 1:1333 N BLUE LAKE LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1234
Mailing Address - Country:US
Mailing Address - Phone:719-671-1016
Mailing Address - Fax:
Practice Address - Street 1:1333 N BLUE LAKE LN
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007
Practice Address - Country:US
Practice Address - Phone:719-671-1016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO275778224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant