MEDICARE: HOLLY LOU ANN HOLYK OTR/L

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	225XL0004X	Low Vision Occupational Therapist	1122	CA

General Provider Information

NPI Number	:	1912265554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY LOU ANN HOLYK OTR/L

Provider Business Mailing Address
First Line	:	875 S VICTORIA AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-3752
Country	:	US
Telephone Number	:	323-939-4040
Fax Number	:

Provider Business Practice Location Address
First Line	:	875 S VICTORIA AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-3752
Country	:	US
Telephone Number	:	323-939-4040
Fax Number	:

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

Provider Enumeration Date	:	05/02/2012
Last Update Date	:	05/02/2012

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