Provider Demographics
NPI:1194178293
Name:DAVIS, HOLLIE DENISE (PTA)
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:DENISE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 N MCCAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:ARANSAS PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78336-2912
Mailing Address - Country:US
Mailing Address - Phone:361-727-6142
Mailing Address - Fax:
Practice Address - Street 1:1610 N MCCAMPBELL ST
Practice Address - Street 2:
Practice Address - City:ARANSAS PASS
Practice Address - State:TX
Practice Address - Zip Code:78336-2912
Practice Address - Country:US
Practice Address - Phone:361-727-6142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2082391314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility