Provider Demographics
NPI:1114264397
Name:HOLMSTROM, DANIELLE CHARLOTTE MARIE
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:CHARLOTTE MARIE
Last Name:HOLMSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:DANIELLE
Other - Middle Name:CHARLOTTE MARIE
Other - Last Name:LOFTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:2433 SW 54TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-6019
Mailing Address - Country:US
Mailing Address - Phone:405-532-7608
Mailing Address - Fax:
Practice Address - Street 1:14625 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8728
Practice Address - Country:US
Practice Address - Phone:405-390-8131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5797101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200481330BMedicaid