Provider Demographics
NPI:1831215474
Name:HOLDER, KIM E (LMP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:E
Last Name:HOLDER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:E
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:8390 W GAGE BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-8105
Mailing Address - Country:US
Mailing Address - Phone:509-374-2600
Mailing Address - Fax:
Practice Address - Street 1:8390 W GAGE BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-8105
Practice Address - Country:US
Practice Address - Phone:509-374-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015620225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0164297OtherLABOR & INDUSTRIES
WA239007239006OtherAWHN