Provider Demographics
NPI:1891239687
Name:SCOTT-RODRIGUEZ, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:SCOTT-RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 PROBST DR
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3316
Mailing Address - Country:US
Mailing Address - Phone:631-560-4006
Mailing Address - Fax:
Practice Address - Street 1:57 PROBST DRIVE
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967
Practice Address - Country:US
Practice Address - Phone:631-560-4006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
NY011184-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician