Provider Demographics
NPI:1871288803
Name:LIESEGANG, HOLLY (OTR/L)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:LIESEGANG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 OLD CAMP CATAWBA RD
Mailing Address - Street 2:
Mailing Address - City:BLOWING ROCK
Mailing Address - State:NC
Mailing Address - Zip Code:28605-9220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4335 PHEASANT RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-5272
Practice Address - Country:US
Practice Address - Phone:540-725-8210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119009869.225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist