Basic Information
| Provider Information | |||||||||
| NPI: | 1669983672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLSTON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Credential: | LICDC, QMHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 108 | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456380108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405321613 | ||||||||
| FaxNumber: | 7405321715 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405321613 | ||||||||
| FaxNumber: | 7405321715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2017 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCDCIII.162003 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | LICDC.162215 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0381739 | 05 | OH | MEDICAID |