Provider Demographics
NPI:1114074895
Name:RACZ, HOLLIE (PTA)
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:
Last Name:RACZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:HOLLIE
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:730 THIMBLE SHOALS BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4562
Mailing Address - Country:US
Mailing Address - Phone:757-873-1554
Mailing Address - Fax:
Practice Address - Street 1:730 THIMBLE SHOALS BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4562
Practice Address - Country:US
Practice Address - Phone:757-873-1554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601922225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2306601922OtherSTATE LICENSE