Healthcare Provider Details

I. General information

NPI: 1083982763
Provider Name (Legal Business Name): MARY HOLLENBACK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 AUSTIN BLUFFS PKWY 105
COLORADO SPRINGS CO
80918-5701
US

IV. Provider business mailing address

3425 AUSTIN BLUFFS PKWY 105
COLORADO SPRINGS CO
80918-5701
US

V. Phone/Fax

Practice location:
  • Phone: 719-265-6601
  • Fax: 719-265-6649
Mailing address:
  • Phone: 719-265-6601
  • Fax: 719-265-6649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: