Provider Demographics
NPI:1457501553
Name:HOLLABAUGH, KATHLEEN M
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:HOLLABAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:4324 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELBA
Mailing Address - State:NY
Mailing Address - Zip Code:14058-9763
Mailing Address - Country:US
Mailing Address - Phone:585-757-9992
Mailing Address - Fax:
Practice Address - Street 1:4324 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELBA
Practice Address - State:NY
Practice Address - Zip Code:14058-9763
Practice Address - Country:US
Practice Address - Phone:585-757-9992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006877-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant