Provider Demographics
NPI:1952999278
Name:MONTENEGRO, HOLLIE (COTA)
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:
Last Name:MONTENEGRO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:HOLLIE
Other - Middle Name:
Other - Last Name:MONTENEGRO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:811 E MILLER ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-6845
Mailing Address - Country:US
Mailing Address - Phone:309-261-9242
Mailing Address - Fax:
Practice Address - Street 1:211 LANDMARK DR STE D3
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6107
Practice Address - Country:US
Practice Address - Phone:309-451-5925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-03
Last Update Date:2021-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057004143224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty