Provider Demographics
NPI:1942862461
Name:HANSON, HOLLY LOUISE X
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LOUISE
Last Name:HANSON
Suffix:X
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 1:15 E BRADLEY ST LOT 3
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-6870
Mailing Address - Country:US
Mailing Address - Phone:850-502-3008
Mailing Address - Fax:
Practice Address - Street 1:195 MATTIE M KELLY BLVD
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2811
Practice Address - Country:US
Practice Address - Phone:850-654-4588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-04
Last Update Date:2019-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT17626225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist