Provider Demographics
NPI:1073277380
Name:HOLMAN, SAMANTHA SHADE (COTA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:SHADE
Last Name:HOLMAN
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 1:10196 US HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-8622
Mailing Address - Country:US
Mailing Address - Phone:505-634-8869
Mailing Address - Fax:
Practice Address - Street 1:702 W DOLF ST
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:WI
Practice Address - Zip Code:54421-9604
Practice Address - Country:US
Practice Address - Phone:715-223-2352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant