Provider Demographics
NPI:1003144916
Name:HOLDER, WANDA NERENE (LICENSE MASSAGE THER)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:NERENE
Last Name:HOLDER
Suffix:
Gender:F
Credentials:LICENSE MASSAGE THER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 W COLLIN ST
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-4242
Mailing Address - Country:US
Mailing Address - Phone:903-874-1703
Mailing Address - Fax:
Practice Address - Street 1:322 W 7TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-6402
Practice Address - Country:US
Practice Address - Phone:903-872-2756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-04
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT010527225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist