Provider Demographics
NPI:1477684744
Name:TRIESTRAM, HOLLY K (LMSW)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:K
Last Name:TRIESTRAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 TACOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2700
Mailing Address - Country:US
Mailing Address - Phone:517-281-5296
Mailing Address - Fax:
Practice Address - Street 1:4660 MARSH RD
Practice Address - Street 2:13
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2143
Practice Address - Country:US
Practice Address - Phone:517-281-5296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical