Basic Information
Provider Information | |||||||||
NPI: | 1679646863 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLLOWAY | ||||||||
FirstName: | DEBRA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RESSLER | ||||||||
OtherFirstName: | DEBRA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 790 REMINGTON BLVD | ||||||||
Address2: |   | ||||||||
City: | BOLINGBROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 604404909 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302962223 | ||||||||
FaxNumber: | 6307593251 | ||||||||
Practice Location | |||||||||
Address1: | 137 W HIGH ST STE 3 | ||||||||
Address2: |   | ||||||||
City: | ELKTON | ||||||||
State: | MD | ||||||||
PostalCode: | 219218600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103927027 | ||||||||
FaxNumber: | 4103925768 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2006 | ||||||||
LastUpdateDate: | 04/01/2016 | ||||||||
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 | 225X00000X | U10000067 | DE | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225X00000X | 06504 | MD | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 0742831000 | 01 | PA | AMERIHEALTH/IBC | OTHER | 1679646863 | 01 |   | CHAMPUS TRICARE | OTHER |