Provider Demographics
NPI:1538640842
Name:HOLY, CLINTON DANIEL (COTA)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:DANIEL
Last Name:HOLY
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:GLENN HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:75154-2024
Mailing Address - Country:US
Mailing Address - Phone:469-386-7430
Mailing Address - Fax:
Practice Address - Street 1:101 REESE DR
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-2376
Practice Address - Country:US
Practice Address - Phone:469-386-7430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211866224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty