Provider Demographics
NPI:1639851827
Name:HOLLIS, STEPHANIE DYANNE (LMT)
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:DYANNE
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3060 PHARR COURT NORTH NW APT 302
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2025
Mailing Address - Country:US
Mailing Address - Phone:901-319-8892
Mailing Address - Fax:
Practice Address - Street 1:3060 PHARR COURT NORTH NW APT 302
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2025
Practice Address - Country:US
Practice Address - Phone:901-319-8892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT014647225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist