=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902314636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY MEYER PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2018
-----------------------------------------------------
Last Update Date | 01/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16125 DIX TOLEDO RD
-----------------------------------------------------
City | SOUTHGATE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48195-2948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-285-1070
-----------------------------------------------------
Fax | 734-285-1073
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1782 CHESTNUT ST
-----------------------------------------------------
City | WYANDOTTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48192-4805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-282-2193
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 5501004180
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------