1043608706 NPI number — MRS. HEATHER MARIE HOLT MSW, LICSW

Table of content: MRS. HEATHER MARIE HOLT MSW, LICSW (NPI 1043608706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043608706 NPI number — MRS. HEATHER MARIE HOLT MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLT
Provider First Name:
HEATHER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VARGO
Provider Other First Name:
HEATHER
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043608706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1619 DAYTON AVE STE 112B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55104-6276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-889-7517
Provider Business Mailing Address Fax Number:
651-389-0510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1619 DAYTON AVE
Provider Second Line Business Practice Location Address:
STE 112B
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104-6206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-889-7517
Provider Business Practice Location Address Fax Number:
651-389-0510
Provider Enumeration Date:
01/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  21742 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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