Provider Demographics
NPI:1053926816
Name:HOLLOWAY, TYLER JAMES (OTR/L)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16171 N BRINSON ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-5509
Mailing Address - Country:US
Mailing Address - Phone:208-442-2525
Mailing Address - Fax:
Practice Address - Street 1:16171 N BRINSON ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5509
Practice Address - Country:US
Practice Address - Phone:208-442-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-2206225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics