Basic Information
Provider Information | |||||||||
NPI: | 1396110227 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLLIS | ||||||||
FirstName: | CAITLIN | ||||||||
MiddleName: | BRI | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WEBER | ||||||||
OtherFirstName: | CAITLIN | ||||||||
OtherMiddleName: | BRI | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PTA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1100 SHAWNEE ROAD | ||||||||
Address2: |   | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 45805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4199992030 | ||||||||
FaxNumber: | 4199910909 | ||||||||
Practice Location | |||||||||
Address1: | 640 WORTH ST | ||||||||
Address2: |   | ||||||||
City: | CORRY | ||||||||
State: | PA | ||||||||
PostalCode: | 164078515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8146649606 | ||||||||
FaxNumber: | 8146650036 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2015 | ||||||||
LastUpdateDate: | 12/03/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | TE009763 | PA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.