Basic Information
| Provider Information | |||||||||
| NPI: | 1881740892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASOM | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | ERIN | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 OLIVE ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631032303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142063700 | ||||||||
| FaxNumber: | 3142063708 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 OLIVE ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631032303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142063700 | ||||||||
| FaxNumber: | 3142063708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 101YM0800X | 2014012314 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2014012314 | 01 | MO | LPC | OTHER |