Basic Information
| Provider Information | |||||||||
| NPI: | 1306372958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | AMANDA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FREEMAN | ||||||||
| OtherFirstName: | HOLLY | ||||||||
| OtherMiddleName: | AMANDA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 E VETERANS STREET | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083723971 | ||||||||
| FaxNumber: | 7152841398 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 E VETERANS STREET | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083723971 | ||||||||
| FaxNumber: | 7152841398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2017 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 6089-26 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XP0019X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 6089-26 | 01 | WI | WISCONSIN LICENSE NUMBER | OTHER |