Provider Demographics
NPI:1689273682
Name:PROWANT, HOLLY (COTA/L)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:PROWANT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 N STAFFIRE DR
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60194-3857
Mailing Address - Country:US
Mailing Address - Phone:630-415-5044
Mailing Address - Fax:
Practice Address - Street 1:750 PASQUINELLI DR STE 204
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1291
Practice Address - Country:US
Practice Address - Phone:630-560-0136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005391224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant