Provider Demographics
NPI:1689485146
Name:PACE, HOLLY NOELLE (OTR/L)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:NOELLE
Last Name:PACE
Suffix:
Gender:F
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 1:1053 W 110 S
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-6057
Mailing Address - Country:US
Mailing Address - Phone:801-425-5464
Mailing Address - Fax:
Practice Address - Street 1:240 W BURNSIDE AVE STE D
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-4703
Practice Address - Country:US
Practice Address - Phone:208-904-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-2890225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics