Basic Information
| Provider Information | |||||||||
| NPI: | 1952999278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTENEGRO | ||||||||
| FirstName: | HOLLIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | COTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MONTENEGRO | ||||||||
| OtherFirstName: | HOLLIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | COTA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 811 E MILLER ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617016845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092619242 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 211 LANDMARK DR STE D3 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617616107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094515925 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2021 | ||||||||
| LastUpdateDate: | 01/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 057004143 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.