Provider Demographics
NPI:1225392822
Name:BOIVIN, KATHLEEN (LMT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BOIVIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E SHIPWRECK RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-3014
Mailing Address - Country:US
Mailing Address - Phone:850-654-7287
Mailing Address - Fax:
Practice Address - Street 1:105 E SHIPWRECK RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-3014
Practice Address - Country:US
Practice Address - Phone:850-654-7287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLMT 69153225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist