Provider Demographics
NPI:1336315415
Name:HOLMES, ANGELA ILENE (LMT)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:ILENE
Last Name:HOLMES
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 1:2641 SW HUBER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-6338
Mailing Address - Country:US
Mailing Address - Phone:503-891-6769
Mailing Address - Fax:
Practice Address - Street 1:2641 SW HUBER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-6338
Practice Address - Country:US
Practice Address - Phone:503-891-6769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORNIA WHITE BELT225600000X
OR11246225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist