Provider Demographics
NPI:1114945938
Name:HOLMAN, MARY ALETHEA (MSSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALETHEA
Last Name:HOLMAN
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 JANESVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-2727
Mailing Address - Country:US
Mailing Address - Phone:920-563-9375
Mailing Address - Fax:920-563-9576
Practice Address - Street 1:1631 JANESVILLE AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-2727
Practice Address - Country:US
Practice Address - Phone:920-563-9375
Practice Address - Fax:920-563-9576
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4155-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39277500Medicaid