Provider Demographics
NPI:1457816449
Name:MAHAN, HOLLY (PTA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:MAHAN
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 1:2300 HAGGERTY RD STE 1110
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2185
Mailing Address - Country:US
Mailing Address - Phone:248-669-2000
Mailing Address - Fax:248-669-2110
Practice Address - Street 1:2300 HAGGERTY RD STE 1110
Practice Address - Street 2:
Practice Address - City:W BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2185
Practice Address - Country:US
Practice Address - Phone:248-669-2000
Practice Address - Fax:248-669-2110
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003415225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant