Provider Demographics
NPI:1104553353
Name:HEBERLEIN, HOLLY ANN
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:HEBERLEIN
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 1:420 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-4350
Mailing Address - Country:US
Mailing Address - Phone:715-712-1370
Mailing Address - Fax:715-712-1341
Practice Address - Street 1:420 3RD ST S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4350
Practice Address - Country:US
Practice Address - Phone:715-712-1370
Practice Address - Fax:715-712-1341
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty