Provider Demographics
NPI:1518668136
Name:VANDERHOLM, MARY ELISE (CMHC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELISE
Last Name:VANDERHOLM
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 E 2450 S # 5A
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-6285
Mailing Address - Country:US
Mailing Address - Phone:435-227-5506
Mailing Address - Fax:
Practice Address - Street 1:1611 E 2450 S # 5A
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6285
Practice Address - Country:US
Practice Address - Phone:435-227-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11866328-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health