Basic Information
| Provider Information | |||||||||
| NPI: | 1770794364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLODY | ||||||||
| FirstName: | SHEILA | ||||||||
| MiddleName: | CLARE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 809 | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465270809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745372674 | ||||||||
| FaxNumber: | 5745372652 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 LINCOLN WAY W | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465441626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742595666 | ||||||||
| FaxNumber: | 5742556179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34002607A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 35000671A | IN | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.