Healthcare Provider Details

I. General information

NPI: 1871154187
Provider Name (Legal Business Name): COURTNEY NICOLE HOLLINGSWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 W DETROIT ST
BROKEN ARROW OK
74012-3628
US

IV. Provider business mailing address

1511 S BALTIMORE AVE APT 3
TULSA OK
74119-4031
US

V. Phone/Fax

Practice location:
  • Phone: 918-615-6492
  • Fax:
Mailing address:
  • Phone: 573-823-2110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: