Healthcare Provider Details

I. General information

NPI: 1396371233
Provider Name (Legal Business Name): HOLLY BERTSCH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2020
Last Update Date: 03/22/2020
Certification Date: 03/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 COUNCIL ST NE
CEDAR RAPIDS IA
52402-1129
US

IV. Provider business mailing address

6452 N ROCKY RD
EAST DUBUQUE IL
61025-9452
US

V. Phone/Fax

Practice location:
  • Phone: 319-393-1447
  • Fax:
Mailing address:
  • Phone: 563-580-9507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number090699
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: