Provider Demographics
NPI:1417320326
Name:HOLLY, VICTORIA MEGAN (PT)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:MEGAN
Last Name:HOLLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:MEGAN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:90 HOWARD DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8138
Mailing Address - Country:US
Mailing Address - Phone:502-633-1007
Mailing Address - Fax:502-437-0624
Practice Address - Street 1:90 HOWARD DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8138
Practice Address - Country:US
Practice Address - Phone:502-633-1007
Practice Address - Fax:502-437-0624
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist