Provider Demographics
NPI:1609307412
Name:MELLGREN, HOLLY (LMP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:MELLGREN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 N 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:WEST RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99353-9726
Mailing Address - Country:US
Mailing Address - Phone:509-531-2228
Mailing Address - Fax:
Practice Address - Street 1:626 N 61ST AVE
Practice Address - Street 2:
Practice Address - City:WEST RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99353-9726
Practice Address - Country:US
Practice Address - Phone:509-531-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60494059225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist