Provider Demographics
NPI:1235416132
Name:HOLMES, MARYKAY (PTA)
Entity Type:Individual
Prefix:
First Name:MARYKAY
Middle Name:
Last Name:HOLMES
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 1:6200 OSAGE AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-2031
Mailing Address - Country:US
Mailing Address - Phone:630-915-6257
Mailing Address - Fax:
Practice Address - Street 1:94 63RD ST
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-2982
Practice Address - Country:US
Practice Address - Phone:630-850-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004887225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant