Provider Demographics
NPI:1336650084
Name:HOLM, SHIRLEY MARIE O'HEARN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:MARIE O'HEARN
Last Name:HOLM
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 1:34059 SHEEP CAMP RD
Mailing Address - Street 2:
Mailing Address - City:BONNER
Mailing Address - State:MT
Mailing Address - Zip Code:59823-9803
Mailing Address - Country:US
Mailing Address - Phone:406-499-1049
Mailing Address - Fax:
Practice Address - Street 1:113 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4336
Practice Address - Country:US
Practice Address - Phone:406-499-1049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-12457225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist