=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093081366
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY BETH VANCLEAVE PT, DPT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2012
-----------------------------------------------------
Last Update Date | 01/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 S SANTA FE AVE 4TH FLOOR
-----------------------------------------------------
City | SALINA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67401-4190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-452-6668
-----------------------------------------------------
Fax | 785-452-7512
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 S SANTA FE AVE 4TH FLOOR
-----------------------------------------------------
City | SALINA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67401-4190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-452-6668
-----------------------------------------------------
Fax | 785-452-7512
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 11-05160
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2401079
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------