Provider Demographics
NPI:1629126891
Name:HOLDER, KRISTINE (OTR)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:HOLDER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 PEACH ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-6636
Mailing Address - Country:US
Mailing Address - Phone:618-628-0261
Mailing Address - Fax:
Practice Address - Street 1:4700 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5373
Practice Address - Country:US
Practice Address - Phone:618-257-5758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-007501225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001415008OtherBCBS OF IL
5330619OtherAETNA
5330619OtherAETNA