Provider Demographics
NPI:1619448776
Name:VAN BROCKLIN, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:VAN BROCKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 WINCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-4837
Mailing Address - Country:US
Mailing Address - Phone:916-230-4037
Mailing Address - Fax:
Practice Address - Street 1:1600 EUREKA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3027
Practice Address - Country:US
Practice Address - Phone:916-484-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36413227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered