Healthcare Provider Details

I. General information

NPI: 1407276405
Provider Name (Legal Business Name): HOLLY YODER THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 W LINCOLN AVE
GOSHEN IN
46526-5907
US

IV. Provider business mailing address

304 NEBRASKA DR
GOSHEN IN
46526-1434
US

V. Phone/Fax

Practice location:
  • Phone: 574-534-2161
  • Fax: 574-534-3887
Mailing address:
  • Phone: 574-903-6039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34005054A
License Number StateIN

VIII. Authorized Official

Name: MS. HOLLY YODER
Title or Position: OWNER
Credential:
Phone: 574-903-6039