Provider Demographics
NPI:1043236771
Name:MATHIS, HOLLY PULLIAM (MASTERS)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:PULLIAM
Last Name:MATHIS
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 YMCA CAMP RD
Mailing Address - Street 2:
Mailing Address - City:KING
Mailing Address - State:NC
Mailing Address - Zip Code:27021-8619
Mailing Address - Country:US
Mailing Address - Phone:336-985-4601
Mailing Address - Fax:
Practice Address - Street 1:1802 CARMEL RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-3120
Practice Address - Country:US
Practice Address - Phone:336-282-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC079JTOtherBLUE CROSS
NC7211246Medicaid