Provider Demographics
NPI:1033719901
Name:HOLLOWAY, CHARLOTTE SABINA
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:SABINA
Last Name:HOLLOWAY
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 1:1353 SAN JUAN DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3493
Mailing Address - Country:US
Mailing Address - Phone:312-952-4823
Mailing Address - Fax:
Practice Address - Street 1:618 PASEO DE PERALTA STE A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1984
Practice Address - Country:US
Practice Address - Phone:505-989-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM9054225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist