Provider Demographics
NPI:1790310498
Name:WAGGONER, HOLLY LYNNE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:LYNNE
Last Name:WAGGONER
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 1:14112 N RIVER CREST DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:IL
Mailing Address - Zip Code:61523-9311
Mailing Address - Country:US
Mailing Address - Phone:309-251-7194
Mailing Address - Fax:
Practice Address - Street 1:1028 W HILLCREST DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:IL
Practice Address - Zip Code:61523-2258
Practice Address - Country:US
Practice Address - Phone:309-274-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005036224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant