Provider Demographics
NPI:1619546397
Name:HENDRICKS, HOLLY (MS, CSCS)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:MS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15472 DERBY GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-9417
Mailing Address - Country:US
Mailing Address - Phone:319-899-9457
Mailing Address - Fax:
Practice Address - Street 1:2300 JOHN F KENNEDY RD STE 1
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2843
Practice Address - Country:US
Practice Address - Phone:563-588-3891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005673225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist