Provider Demographics
NPI:1962670281
Name:LODGE, HOLLY (MT)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:
Last Name:LODGE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 EDGEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4167
Mailing Address - Country:US
Mailing Address - Phone:313-930-9139
Mailing Address - Fax:
Practice Address - Street 1:3413 EDGEWOOD ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4167
Practice Address - Country:US
Practice Address - Phone:313-930-9139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist