Provider Demographics
NPI:1730642851
Name:COOTS, HOLLY NICOLE
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:NICOLE
Last Name:COOTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:NICOLE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT
Mailing Address - Street 1:40 STATE HIGHWAY 83
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-7404
Mailing Address - Country:US
Mailing Address - Phone:850-585-9189
Mailing Address - Fax:850-951-0898
Practice Address - Street 1:40 STATE HIGHWAY 83
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-7404
Practice Address - Country:US
Practice Address - Phone:850-585-9189
Practice Address - Fax:850-951-0898
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician