Provider Demographics
NPI:1992149777
Name:CORDERO, HOLLY RENEE
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:RENEE
Last Name:CORDERO
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 1:13224 E TALL TREE RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-2411
Mailing Address - Country:US
Mailing Address - Phone:509-924-1506
Mailing Address - Fax:
Practice Address - Street 1:13224 E TALL TREE RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2411
Practice Address - Country:US
Practice Address - Phone:509-924-1506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA364500320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities