Provider Demographics
NPI:1457902660
Name:KETVIRTIS, HOLLI JOANNE
Entity Type:Individual
Prefix:
First Name:HOLLI
Middle Name:JOANNE
Last Name:KETVIRTIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-2829
Mailing Address - Country:US
Mailing Address - Phone:360-513-5344
Mailing Address - Fax:
Practice Address - Street 1:409 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-2829
Practice Address - Country:US
Practice Address - Phone:360-513-5344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-28
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61383977225700000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician