Basic Information
| Provider Information | |||||||||
| NPI: | 1164684072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLDER | ||||||||
| FirstName: | LORRAINE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CASAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVIS | ||||||||
| OtherFirstName: | LORRAINE | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | PROF. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 34 | ||||||||
| Address2: | |||||||||
| City: | FERNDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127340034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457474347 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20 COMMUNITY LN | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127542851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452928770 | ||||||||
| FaxNumber: | 8452924206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2008 | ||||||||
| LastUpdateDate: | 07/01/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 19885 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.