Provider Demographics
NPI:1184956740
Name:HOLLER, SANTISHA A (LMP)
Entity type:Individual
Prefix:
First Name:SANTISHA
Middle Name:A
Last Name:HOLLER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6460 E BEAVER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-8223
Mailing Address - Country:US
Mailing Address - Phone:360-710-6981
Mailing Address - Fax:
Practice Address - Street 1:11871 SILVERDALE WAY NW STE 103
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9414
Practice Address - Country:US
Practice Address - Phone:360-710-6981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-08
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60103672225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist