Provider Demographics
NPI:1366648719
Name:DIBERT, HOLLY JOY I (ATC)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:JOY
Last Name:DIBERT
Suffix:I
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 AVERY PARK CIR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30360-2576
Mailing Address - Country:US
Mailing Address - Phone:404-285-5560
Mailing Address - Fax:
Practice Address - Street 1:1014 SYCAMORE DR STE B
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1644
Practice Address - Country:US
Practice Address - Phone:404-299-1700
Practice Address - Fax:404-299-1616
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00300174400000X
MN1835174400000X
GA10-0825246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1518959006OtherDR. BENDIKS
GAGRP2711Medicare UPIN