Basic Information
Provider Information | |||||||||
NPI: | 1053465914 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALTERS | ||||||||
FirstName: | HOLLY | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 66 E 3RD ST | ||||||||
Address2: | 201 | ||||||||
City: | WINONA | ||||||||
State: | MN | ||||||||
PostalCode: | 559873478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5074527292 | ||||||||
FaxNumber: | 5074579887 | ||||||||
Practice Location | |||||||||
Address1: | 1707 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LA CROSSE | ||||||||
State: | WI | ||||||||
PostalCode: | 546014200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087850001 | ||||||||
FaxNumber: | 6087850002 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/22/2007 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3719-125 | WI | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 00271 | MN | N |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | HP66806 | 01 | MN | HEALTHPARTNERS | OTHER | 40999200 | 05 | WI |   | MEDICAID | 401K8WA | 01 | MN | BCBS-MN | OTHER |