Healthcare Provider Details

I. General information

NPI: 1215842448
Provider Name (Legal Business Name): KATIE MARIE LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATIE MARIE HOLESKI LMT

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1754 CAMP NINE RD
BONNERS FERRY ID
83805-6085
US

IV. Provider business mailing address

1754 CAMP NINE RD
BONNERS FERRY ID
83805-6085
US

V. Phone/Fax

Practice location:
  • Phone: 208-627-8242
  • Fax:
Mailing address:
  • Phone: 208-627-8242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMASG-2332
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: