Provider Demographics
NPI:1619238524
Name:BESAW, HOLLY ANN (MS)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:ANN
Last Name:BESAW
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MRS
Other - First Name:HOLLY
Other - Middle Name:ANN
Other - Last Name:HOWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:216 COUNTY ROUTE 64
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:NY
Mailing Address - Zip Code:13114-3229
Mailing Address - Country:US
Mailing Address - Phone:315-963-3680
Mailing Address - Fax:
Practice Address - Street 1:216 COUNTY ROUTE 64
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-3229
Practice Address - Country:US
Practice Address - Phone:315-963-3680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist