Provider Demographics
NPI:1417414673
Name:TAVERA, HOLLY CATHERINE GRACE (OT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:CATHERINE GRACE
Last Name:TAVERA
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 1:2500 E PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9718
Mailing Address - Country:US
Mailing Address - Phone:970-493-0112
Mailing Address - Fax:970-493-1794
Practice Address - Street 1:1610 DRY CREEK DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6405
Practice Address - Country:US
Practice Address - Phone:720-494-4750
Practice Address - Fax:970-493-1794
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007709225X00000X
COOT.0006677225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist