Healthcare Provider Details

I. General information

NPI: 1629456025
Provider Name (Legal Business Name): HOLLY CAUDILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 S WILLIAMSON BLVD
PORT ORANGE FL
32128
US

IV. Provider business mailing address

5022 DOCKSIDE DR
WILMINGTON NC
28409-3721
US

V. Phone/Fax

Practice location:
  • Phone: 888-265-2680
  • Fax:
Mailing address:
  • Phone: 910-508-7446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT60911713
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: