Basic Information
| Provider Information | |||||||||
| NPI: | 1164935227 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLOUSE | ||||||||
| FirstName: | HOLLIE | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 WILDERNESS RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLESBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062429336 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 PAMALEE DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283012824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882295 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2017 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 3559 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 11360 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3559 | 01 | TN | TN BOARD OF OT | OTHER |