Healthcare Provider Details

I. General information

NPI: 1336804517
Provider Name (Legal Business Name): HOLLIE ELIZABETH VANDERHEIDE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 MAIN STREET
AFTON NY
13730
US

IV. Provider business mailing address

193 MAIN STREET
AFTON NY
13730
US

V. Phone/Fax

Practice location:
  • Phone: 607-383-0553
  • Fax:
Mailing address:
  • Phone: 607-383-0553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number026994-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number026994
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: