Provider Demographics
NPI:1619913076
Name:NEISWENDER, HOLLY (PT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:NEISWENDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 E HENRY AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-4432
Mailing Address - Country:US
Mailing Address - Phone:813-239-1179
Mailing Address - Fax:813-237-3091
Practice Address - Street 1:2215 E HENRY AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4432
Practice Address - Country:US
Practice Address - Phone:813-239-1179
Practice Address - Fax:813-237-3091
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0002911222Q00000X
FLPTOOO2911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL880492301Medicaid
FL000122200Medicaid