Provider Demographics
NPI:1841564374
Name:HINES, KATHLEEN MARIE (MSOTR, NCTMB)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:HINES
Suffix:
Gender:F
Credentials:MSOTR, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 OLD TOWN SQ
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-2471
Mailing Address - Country:US
Mailing Address - Phone:970-310-7789
Mailing Address - Fax:970-482-0251
Practice Address - Street 1:19 OLD TOWN SQ
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-2471
Practice Address - Country:US
Practice Address - Phone:970-310-7789
Practice Address - Fax:970-482-0251
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2914225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2914OtherSTATE OF COLORADO DEPARTMENT OF REGULATORY AGENCIES