Healthcare Provider Details

I. General information

NPI: 1184549370
Provider Name (Legal Business Name): MR. FREDERICK HOLLEY IV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 KEMPTON ST
SPRING VALLEY CA
91977-5810
US

IV. Provider business mailing address

7621 EADS AVE APT 1B
LA JOLLA CA
92037-4820
US

V. Phone/Fax

Practice location:
  • Phone: 619-479-4790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number20401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: