Healthcare Provider Details

I. General information

NPI: 1992123608
Provider Name (Legal Business Name): HOLLY BROACH OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 LINCOLN PARK BLVD
KETTERING OH
45429-3474
US

IV. Provider business mailing address

5433 RED COACH RD
CENTERVILLE OH
45429-6113
US

V. Phone/Fax

Practice location:
  • Phone: 937-499-1400
  • Fax:
Mailing address:
  • Phone: 937-838-2366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA 02967
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number008756
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: