Provider Demographics
NPI:1336804517
Name:VANDERHEIDE, HOLLIE ELIZABETH (LMT)
Entity Type:Individual
Prefix:MRS
First Name:HOLLIE
Middle Name:ELIZABETH
Last Name:VANDERHEIDE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:NY
Mailing Address - Zip Code:13730
Mailing Address - Country:US
Mailing Address - Phone:607-383-0553
Mailing Address - Fax:
Practice Address - Street 1:193 MAIN STREET
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:NY
Practice Address - Zip Code:13730
Practice Address - Country:US
Practice Address - Phone:607-383-0553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026994-1225700000X
NY026994225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty