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General NPI Number Information
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NPI Number | 1912399569
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Entity Type | Individual
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Provider Name | HOLLIS THEARD ATC, LAT
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Gender | Female
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Dates
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Enumeration Date | 02/19/2015
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Last Update Date | 09/09/2015
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Provider Practice Location Address
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Address Line | 49464 MERNER TERRACE
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City | MISENHEIMER
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State | NC
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Zip | 28109
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Country | US
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Telephone | 704-463-0567
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Fax |
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Provider Business Mailing Address
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Address Line | 435 EASTWOOD DR
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City | SALISBURY
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State | NC
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Zip | 28146-7063
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT001791
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | LAT-2778
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | ATH.200482
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License Number State | LA
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