Basic Information
| Provider Information | |||||||||
| NPI: | 1053780882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2320 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834046448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085232344 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2235 E 25TH ST | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086122272 | ||||||||
| FaxNumber: | 8884457083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2015 | ||||||||
| LastUpdateDate: | 09/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LCPC 2674 | ID | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.