Provider Demographics
NPI:1225463482
Name:DEROSSETT, HOLLY DEEN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:DEEN
Last Name:DEROSSETT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:HOLLY
Other - Middle Name:REBECCA
Other - Last Name:DEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:2420 BEMISS RD.
Mailing Address - Street 2:SUITE B
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-293-9511
Mailing Address - Fax:229-293-9141
Practice Address - Street 1:2420 BEMISS RD.
Practice Address - Street 2:SUITE B
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-293-9511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT005886225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist