Healthcare Provider Details

I. General information

NPI: 1336767011
Provider Name (Legal Business Name): HOLLEY BASHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 SW 103RD AVE APT 304
PEMBROKE PINES FL
33025-1881
US

IV. Provider business mailing address

403 SW 103RD AVE APT 304
PEMBROKE PINES FL
33025-1881
US

V. Phone/Fax

Practice location:
  • Phone: 954-330-7611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number19-83055
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: