Provider Demographics
NPI:1346751146
Name:HOLST, LIDA A
Entity Type:Individual
Prefix:
First Name:LIDA
Middle Name:A
Last Name:HOLST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10187
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-5187
Mailing Address - Country:US
Mailing Address - Phone:207-777-4111
Mailing Address - Fax:207-783-6660
Practice Address - Street 1:670 PARK AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MT
Practice Address - Zip Code:59474-1663
Practice Address - Country:US
Practice Address - Phone:406-434-3110
Practice Address - Fax:406-434-3143
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC16835104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT40408OtherMT LICENSE