Provider Demographics
NPI:1336891159
Name:MARTIN, HOLLIE
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:
Last Name:MARTIN
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 1:26357 COUNTY HWY Y
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-8721
Mailing Address - Country:US
Mailing Address - Phone:608-632-1641
Mailing Address - Fax:
Practice Address - Street 1:1400 W SEMINARY ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-2036
Practice Address - Country:US
Practice Address - Phone:608-647-8931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5747-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant