Provider Demographics
NPI:1750451308
Name:SMITH, HOLLY SUZANNE (OTRL)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:SUZANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6513
Mailing Address - Country:US
Mailing Address - Phone:423-967-5326
Mailing Address - Fax:
Practice Address - Street 1:629 W ELK AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2559
Practice Address - Country:US
Practice Address - Phone:423-543-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT0000003042171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor