Provider Demographics
NPI:1710562780
Name:HOLLISTER, MARIAH (PTA)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:HOLLISTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 MCCLAIN DR
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-2715
Mailing Address - Country:US
Mailing Address - Phone:580-682-3044
Mailing Address - Fax:
Practice Address - Street 1:911 MCCLAIN DR
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-2715
Practice Address - Country:US
Practice Address - Phone:580-682-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3131225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3131OtherPTA LICENSE
OK200967320AMedicaid