MEDICARE: KELLY HOLTZ

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	222Q00000X	Developmental Therapist	H43250190820	IL

General Provider Information

NPI Number	:	1942656814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY HOLTZ

Provider Business Mailing Address
First Line	:	1544 W CHESTNUT ST
Second Line	:	APT. 2F
City	:	CHICAGO
State	:	IL
Zip	:	60642-5201
Country	:	US
Telephone Number	:	773-510-9465
Fax Number	:

Provider Business Practice Location Address
First Line	:	1544 W CHESTNUT ST
Second Line	:	APT. 2F
City	:	CHICAGO
State	:	IL
Zip	:	60642-5201
Country	:	US
Telephone Number	:	773-510-9465
Fax Number	:

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

Provider Enumeration Date	:	05/10/2016
Last Update Date	:	05/10/2016

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