Provider Demographics
NPI:1134662547
Name:DEPTULA, HOLLY LYNN
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LYNN
Last Name:DEPTULA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 S ALBANY AVE
Mailing Address - Street 2:APT 5
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2457
Mailing Address - Country:US
Mailing Address - Phone:609-712-3890
Mailing Address - Fax:
Practice Address - Street 1:607 S ALBANY AVE
Practice Address - Street 2:APT 5
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2457
Practice Address - Country:US
Practice Address - Phone:609-712-3890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst