Provider Demographics
NPI:1619204195
Name:HOLLER, TIFFANY DAWN (COTA/L)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DAWN
Last Name:HOLLER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300B RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-3903
Mailing Address - Country:US
Mailing Address - Phone:316-734-4735
Mailing Address - Fax:
Practice Address - Street 1:600 W BLANCHARD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67505-1526
Practice Address - Country:US
Practice Address - Phone:620-663-7175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00593224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant