Provider Demographics
NPI:1831446335
Name:VAN HORN, NICOLE CAROLYN (LMT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CAROLYN
Last Name:VAN HORN
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 1:1318 S 3RD ST W STE 3
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2364
Mailing Address - Country:US
Mailing Address - Phone:406-327-5325
Mailing Address - Fax:
Practice Address - Street 1:1318 S 3RD ST W STE 3
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2364
Practice Address - Country:US
Practice Address - Phone:406-327-5325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-2861225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist