Provider Demographics
NPI:1942656814
Name:HOLTZ, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HOLTZ
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 1:1544 W CHESTNUT ST
Mailing Address - Street 2:APT. 2F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-5201
Mailing Address - Country:US
Mailing Address - Phone:773-510-9465
Mailing Address - Fax:
Practice Address - Street 1:1544 W CHESTNUT ST
Practice Address - Street 2:APT. 2F
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-5201
Practice Address - Country:US
Practice Address - Phone:773-510-9465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILH43250190820222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist