Basic Information
| Provider Information | |||||||||
| NPI: | 1144399015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLDERBACH | ||||||||
| FirstName: | HANNEKE | ||||||||
| MiddleName: | JAMIESON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | COTA/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JAMIESON | ||||||||
| OtherFirstName: | HANNEKE | ||||||||
| OtherMiddleName: | JANET | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5701 SW MULTNOMAH BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972193195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5701 SW MULTNOMAH BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972193195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032441107 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 03/03/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 0730113076 | VT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.