Provider Demographics
NPI:1356539969
Name:HOLLAND, AUTUMN LEE (PTA)
Entity type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:LEE
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:AUTUMN
Other - Middle Name:LEE
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1102 W TRAVIS ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624
Mailing Address - Country:US
Mailing Address - Phone:830-997-3781
Mailing Address - Fax:830-997-3786
Practice Address - Street 1:1102 W TRAVIS ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624
Practice Address - Country:US
Practice Address - Phone:830-997-3781
Practice Address - Fax:830-997-3786
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2034999225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant