Provider Demographics
NPI:1114397700
Name:BAXTER, HOLLY (COTA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:BAXTER
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 1:12561 W STATE ROAD 32
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47396-9725
Mailing Address - Country:US
Mailing Address - Phone:765-215-5618
Mailing Address - Fax:
Practice Address - Street 1:12561 W STATE ROAD 32
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47396-9725
Practice Address - Country:US
Practice Address - Phone:765-215-5618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001866A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant