Provider Demographics
NPI:1487286183
Name:HOLTMEYER, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:HOLTMEYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 HIGHWAY A
Mailing Address - Street 2:
Mailing Address - City:IBERIA
Mailing Address - State:MO
Mailing Address - Zip Code:65486-8207
Mailing Address - Country:US
Mailing Address - Phone:573-645-8751
Mailing Address - Fax:
Practice Address - Street 1:174 BALLPARK RD
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:MO
Practice Address - Zip Code:65582-8043
Practice Address - Country:US
Practice Address - Phone:573-422-3177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016003644224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty