Provider Demographics
NPI:1922250083
Name:HOLDEMAN, BEVERLY A (LMT, MMP)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:A
Last Name:HOLDEMAN
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 W CREEDANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-4072
Mailing Address - Country:US
Mailing Address - Phone:623-780-7598
Mailing Address - Fax:
Practice Address - Street 1:4212 W CREEDANCE BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-4072
Practice Address - Country:US
Practice Address - Phone:623-780-7598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT 05786225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT 05786OtherLICENSED MASSAGE THERAPIST
448408 00OtherNATIONAL CERTIFICATION BOARD OF THERAPEUTIC MASSAGE AND BODYWORK
448408 00OtherNATIONAL CERTIFICATION BOARD OF THERAPEUTIC MASSAGE AND BODYWORK