Provider Demographics
NPI:1821392523
Name:BURGESS, HOLLIS C (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:HOLLIS
Middle Name:C
Last Name:BURGESS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1738
Mailing Address - Country:US
Mailing Address - Phone:315-573-3572
Mailing Address - Fax:
Practice Address - Street 1:107 GRANT ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1738
Practice Address - Country:US
Practice Address - Phone:315-573-3572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001644225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist