Provider Demographics
NPI:1043425473
Name:HOLASEK, SUSAN MARIE (LCPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:HOLASEK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 IRONWOOD CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-765-4509
Mailing Address - Fax:208-665-7014
Practice Address - Street 1:190 IRONWOOD CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-765-4509
Practice Address - Fax:208-665-7014
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-205101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0035305Medicaid