Provider Demographics
NPI:1265749295
Name:WAITES, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:WAITES
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 1:22135 THUNDERBOLT DR
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-8915
Mailing Address - Country:US
Mailing Address - Phone:530-388-8247
Mailing Address - Fax:
Practice Address - Street 1:22135 THUNDERBOLT DR
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-8915
Practice Address - Country:US
Practice Address - Phone:530-388-8247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8397225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant