MEDICARE: HOLLIE FORTMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	S1502385	OH

General Provider Information

NPI Number	:	1043685746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLIE FORTMAN

Provider Business Mailing Address
First Line	:	6255 TELEGRAPH RD LOT 209
Second Line	:
City	:	ERIE
State	:	MI
Zip	:	48133-9440
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6255 TELEGRAPH RD LOT 209
Second Line	:
City	:	ERIE
State	:	MI
Zip	:	48133-9440
Country	:	US
Telephone Number	:	971-400-6364
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2015
Last Update Date	:	12/07/2015

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Directions to “ HOLLIE FORTMAN ” Practice Location

Language	Start Address	Practice Location

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