Provider Demographics
NPI:1124542907
Name:GLACIER THERAPIES ONLINE
Entity Type:Organization
Organization Name:GLACIER THERAPIES ONLINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:360-340-9270
Mailing Address - Street 1:15640 NE FOURTH PLAIN BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-5141
Mailing Address - Country:US
Mailing Address - Phone:503-567-6326
Mailing Address - Fax:
Practice Address - Street 1:17920 NE 198TH CT
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-8806
Practice Address - Country:US
Practice Address - Phone:801-851-0543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty