Provider Demographics
NPI:1942445838
Name:WILLOW, KATHLEEN MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:WILLOW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 772
Mailing Address - Street 2:
Mailing Address - City:CRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:81131-0772
Mailing Address - Country:US
Mailing Address - Phone:719-256-5469
Mailing Address - Fax:
Practice Address - Street 1:1798 LONE PINE WAY
Practice Address - Street 2:
Practice Address - City:CRESTONE
Practice Address - State:CO
Practice Address - Zip Code:81131
Practice Address - Country:US
Practice Address - Phone:719-256-5469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2138225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist