Basic Information
| Provider Information | |||||||||
| NPI: | 1235156126 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOVERMALE | ||||||||
| FirstName: | HOLLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 626 TRAIL AVE | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016621997 | ||||||||
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| Practice Location | |||||||||
| Address1: | 626 TRAIL AVE | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016621997 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 07/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 20840 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | KBC4HO-6479501 | 01 | MD | BC/BS | OTHER | S404-0023 | 01 | MD | CAREFIRST | OTHER |