Provider Demographics
NPI:1083235519
Name:HOLDREN, ELIZABETH ASHLEY (LMBT 15683)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ASHLEY
Last Name:HOLDREN
Suffix:
Gender:F
Credentials:LMBT 15683
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 BROOKSTOWN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2539
Mailing Address - Country:US
Mailing Address - Phone:336-997-4075
Mailing Address - Fax:
Practice Address - Street 1:1020 BROOKSTOWN AVE STE 11
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2539
Practice Address - Country:US
Practice Address - Phone:336-997-4075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15683225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist