Basic Information
| Provider Information | |||||||||
| NPI: | 1174662357 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLTMEYER | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MS, PA-C, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1736 E SUNSHINE ST STE 718 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658041369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178603893 | ||||||||
| FaxNumber: | 4178770129 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 E TAMPA ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658061131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178310150 | ||||||||
| FaxNumber: | 4178653479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 03/08/2019 | ||||||||
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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 | 101YP2500X | 002489 | MO | N | Behavioral Health & Social Service Providers | Counselor | Professional | 363A00000X | 2019005000 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 499799815 | 05 | MO | MEDICAID |