Provider Demographics
NPI:1063620581
Name:HOLLINGSWORTH, MARY L (PT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:HOLLINGSWORTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 S PEAR ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5128
Mailing Address - Country:US
Mailing Address - Phone:601-260-4605
Mailing Address - Fax:
Practice Address - Street 1:745 S PEAR ORCHARD RD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5128
Practice Address - Country:US
Practice Address - Phone:601-260-4605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3411225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124646Medicaid
MSPT3411OtherMS LICENSE