Healthcare Provider Details

I. General information

NPI: 1386958775
Provider Name (Legal Business Name): CRYSTAL LYNN HOLIDAY COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 NORCROSS WAY
LAFAYETTE IN
47909-8222
US

IV. Provider business mailing address

1417 NORCROSS WAY
LAFAYETTE IN
47909-8222
US

V. Phone/Fax

Practice location:
  • Phone: 765-418-1552
  • Fax:
Mailing address:
  • Phone: 765-418-1552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32001703A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: