Provider Demographics
NPI:1912399569
Name:THEARD, HOLLIS (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:HOLLIS
Middle Name:
Last Name:THEARD
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 EASTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28146-7063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:49464 MERNER TERRACE
Practice Address - Street 2:
Practice Address - City:MISENHEIMER
Practice Address - State:NC
Practice Address - Zip Code:28109
Practice Address - Country:US
Practice Address - Phone:704-463-0567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0017912255A2300X
NCLAT-27782255A2300X
LAATH.2004822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer