Provider Demographics
NPI:1770347072
Name:HOLLISTER, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HOLLISTER
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 1:303 HONNESS RD
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-2983
Mailing Address - Country:US
Mailing Address - Phone:845-242-7302
Mailing Address - Fax:
Practice Address - Street 1:303 HONNESS RD
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-2983
Practice Address - Country:US
Practice Address - Phone:845-242-7302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144864252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency