Provider Demographics
NPI:1144590712
Name:HOLLAND, MICAH JOSEPH (MS, ATC, PES, CES)
Entity Type:Individual
Prefix:MR
First Name:MICAH
Middle Name:JOSEPH
Last Name:HOLLAND
Suffix:
Gender:M
Credentials:MS, ATC, PES, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 E SOPER ST
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:IL
Mailing Address - Zip Code:61088-9770
Mailing Address - Country:US
Mailing Address - Phone:815-222-1339
Mailing Address - Fax:
Practice Address - Street 1:205 W WACKER DR
Practice Address - Street 2:SUITE 1020
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-1216
Practice Address - Country:US
Practice Address - Phone:312-640-0329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960025012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer