Provider Demographics
NPI:1164149761
Name:BALTHAZOR, HOLLY LOUISE
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LOUISE
Last Name:BALTHAZOR
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 1:1048 HOLLY TREE LN
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-8008
Mailing Address - Country:US
Mailing Address - Phone:920-960-1985
Mailing Address - Fax:
Practice Address - Street 1:438 ASHFORD AVE
Practice Address - Street 2:
Practice Address - City:LOMIRA
Practice Address - State:WI
Practice Address - Zip Code:53048-9578
Practice Address - Country:US
Practice Address - Phone:920-269-4386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI796-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant