Provider Demographics
NPI:1750365755
Name:GULLICKSON, HOLLY K (PT)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:K
Last Name:GULLICKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:K
Other - Last Name:FRITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:915 NE 7TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4515
Mailing Address - Country:US
Mailing Address - Phone:541-728-0974
Mailing Address - Fax:541-728-0159
Practice Address - Street 1:915 NE 7TH ST STE 1
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4515
Practice Address - Country:US
Practice Address - Phone:541-728-0974
Practice Address - Fax:541-728-0159
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007726225100000X
OR4039225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500652195Medicaid
WA8334831Medicaid
ORP01452484OtherRR MEDICARE PTAN
ORP01398074OtherRR MEDICARE PTAN
ORP01452484OtherRR MEDICARE PTAN
ORR164127Medicare PIN