Provider Demographics
NPI:1225724784
Name:HOLLIS, BRIDGETT DESHANE (OTA)
Entity Type:Individual
Prefix:MS
First Name:BRIDGETT
Middle Name:DESHANE
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 CHARLOTTE COURT
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630
Mailing Address - Country:US
Mailing Address - Phone:256-710-8866
Mailing Address - Fax:
Practice Address - Street 1:300 HOSPITAL ST.
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650
Practice Address - Country:US
Practice Address - Phone:256-974-1146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1856OTA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant