Provider Demographics
NPI:1235211814
Name:SHURTLEFF, HOLLY LYNNE (OT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LYNNE
Last Name:SHURTLEFF
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 BEAUREGARD LN
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-7904
Mailing Address - Country:US
Mailing Address - Phone:803-642-8971
Mailing Address - Fax:
Practice Address - Street 1:690 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6348
Practice Address - Country:US
Practice Address - Phone:803-293-4326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC471225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0896Medicaid
SCQ351669262Medicare UPIN