Healthcare Provider Details

I. General information

NPI: 1184180648
Provider Name (Legal Business Name): DIANE HOLLADAY OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 COMMERCIAL CT STE C
VENICE FL
34292-1655
US

IV. Provider business mailing address

15722 IBISRIDGE DR
LITHIA FL
33547-3893
US

V. Phone/Fax

Practice location:
  • Phone: 941-485-0121
  • Fax:
Mailing address:
  • Phone: 317-509-4940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31006806A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number20037
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: