Provider Demographics
NPI:1912013269
Name:BOERSMA, HOLLY ANN (ATC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:BOERSMA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 W DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:DWIGHT
Mailing Address - State:IL
Mailing Address - Zip Code:60420-1221
Mailing Address - Country:US
Mailing Address - Phone:815-584-9474
Mailing Address - Fax:
Practice Address - Street 1:850 BROOK FOREST AVE
Practice Address - Street 2:STE. I
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60431-8513
Practice Address - Country:US
Practice Address - Phone:815-725-4919
Practice Address - Fax:815-725-9449
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer