Provider Demographics
NPI:1538316146
Name:HOLMES, MARY LOUISE (PTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:HOLMES
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 1:3511 OUR STREET
Mailing Address - Street 2:
Mailing Address - City:HENRYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47126
Mailing Address - Country:US
Mailing Address - Phone:502-419-3023
Mailing Address - Fax:
Practice Address - Street 1:3511 OUR ST
Practice Address - Street 2:
Practice Address - City:HENRYVILLE
Practice Address - State:IN
Practice Address - Zip Code:47126-8887
Practice Address - Country:US
Practice Address - Phone:502-419-3023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01044225200000X
IN06001986A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant