Basic Information
Provider Information | |||||||||
NPI: | 1750725628 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLT | ||||||||
FirstName: | MEREDITH | ||||||||
MiddleName: | JEAN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T.A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 401 S SUMMIT ST | ||||||||
Address2: |   | ||||||||
City: | GIRARD | ||||||||
State: | KS | ||||||||
PostalCode: | 667431728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202492152 | ||||||||
FaxNumber: | 6207245291 | ||||||||
Practice Location | |||||||||
Address1: | 302 N HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | GIRARD | ||||||||
State: | KS | ||||||||
PostalCode: | 667432000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6207248291 | ||||||||
FaxNumber: | 6207245291 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2013 | ||||||||
LastUpdateDate: | 04/23/2013 | ||||||||
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 | 14-01792 | KS | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.