Provider Demographics
NPI:1366860520
Name:HOLTER, LISA MARIE (LPCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:HOLTER
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 20TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4705
Mailing Address - Country:US
Mailing Address - Phone:701-271-1613
Mailing Address - Fax:701-235-7359
Practice Address - Street 1:3911 20TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4705
Practice Address - Country:US
Practice Address - Phone:701-271-1613
Practice Address - Fax:701-235-7359
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND721-7-15-12A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND78033Medicaid
ND1457643OtherND MEDICAID