MEDICARE: LISA MICHELLE HOLLOWAY OT, MHL, CAPS

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	225X00000X	Occupational Therapist	104860	TX

General Provider Information

NPI Number	:	1518577469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MICHELLE HOLLOWAY OT, MHL, CAPS

Provider Business Mailing Address
First Line	:	9328 WOOD DUCK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76118-7784
Country	:	US
Telephone Number	:	817-891-3255
Fax Number	:

Provider Business Practice Location Address
First Line	:	9328 WOOD DUCK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76118-7784
Country	:	US
Telephone Number	:	817-891-3255
Fax Number	:

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

Provider Enumeration Date	:	08/05/2020
Last Update Date	:	08/05/2020

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