Provider Demographics
NPI:1790192201
Name:HOLDENER, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:HOLDENER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5215 N RAVENSWOOD AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1668
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5215 N RAVENSWOOD AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1668
Practice Address - Country:US
Practice Address - Phone:773-878-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227007483225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist