Healthcare Provider Details

I. General information

NPI: 1639354756
Provider Name (Legal Business Name): BILLY HOLT L.P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 N CEDAR AVE
TAHLEQUAH OK
74464-6755
US

IV. Provider business mailing address

PO BOX 163
WESTVILLE OK
74965-0163
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-6102
  • Fax:
Mailing address:
  • Phone: 918-723-3458
  • Fax: 918-723-3458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTA395
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: