Provider Demographics
NPI:1053767665
Name:ALLEN, HOLLY (COTA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W DICKSON ST
Mailing Address - Street 2:#1162
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-7217
Mailing Address - Country:US
Mailing Address - Phone:812-568-4150
Mailing Address - Fax:
Practice Address - Street 1:48 W COLT SQUARE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2813
Practice Address - Country:US
Practice Address - Phone:479-582-2740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A856224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant