Healthcare Provider Details

I. General information

NPI: 1942445838
Provider Name (Legal Business Name): KATHLEEN MARIE WILLOW L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2008
Last Update Date: 12/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1798 LONE PINE WAY
CRESTONE CO
81131
US

IV. Provider business mailing address

PO BOX 772
CRESTONE CO
81131-0772
US

V. Phone/Fax

Practice location:
  • Phone: 719-256-5469
  • Fax:
Mailing address:
  • Phone: 719-256-5469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2138
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: