Provider Demographics
NPI:1720367774
Name:CAMPBELL, HOLLY SUE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:SUE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 SAXON ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79605-1625
Mailing Address - Country:US
Mailing Address - Phone:260-760-6411
Mailing Address - Fax:
Practice Address - Street 1:317 SAXON ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-1625
Practice Address - Country:US
Practice Address - Phone:260-760-6411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210429171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210429OtherTEXAS STATE LICENSE FOR OCCUPATIONAL THERAPY ASSISTANT