Provider Demographics
NPI:1184256323
Name:HOLDERIED, HEIDI SUSAN (DPT)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:SUSAN
Last Name:HOLDERIED
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 LONESOME POND RD
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-8321
Mailing Address - Country:US
Mailing Address - Phone:518-891-4293
Mailing Address - Fax:
Practice Address - Street 1:176 US OVAL STE 3
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12903-3914
Practice Address - Country:US
Practice Address - Phone:518-310-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039170208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY039170OtherPHYSICAL THERAPY LICENSE