Basic Information
| Provider Information | |||||||||
| NPI: | 1346751146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLST | ||||||||
| FirstName: | LIDA | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10187 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122015187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077774111 | ||||||||
| FaxNumber: | 2077836660 | ||||||||
| Practice Location | |||||||||
| Address1: | 670 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594741663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064343110 | ||||||||
| FaxNumber: | 4064343143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2017 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | MC16835 | ME | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 40408 | 01 | MT | MT LICENSE | OTHER |