Provider Demographics
NPI:1942732540
Name:HOLLOWAY, DERIC LECHARLES (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:DERIC
Middle Name:LECHARLES
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 TONETTA LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-2915
Mailing Address - Country:US
Mailing Address - Phone:914-325-7197
Mailing Address - Fax:
Practice Address - Street 1:95 TONETTA LAKE WAY
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-2915
Practice Address - Country:US
Practice Address - Phone:914-325-7197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-01
Last Update Date:2017-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008563224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant