Provider Demographics
NPI:1720600547
Name:LASTINE, HOLLY JUSTINE (LCSW, LICSW)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JUSTINE
Last Name:LASTINE
Suffix:
Gender:F
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:JUSTINE
Other - Last Name:STURGES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, LICSW
Mailing Address - Street 1:7895 EAST RIVER ROAD
Mailing Address - Street 2:APT 201
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432
Mailing Address - Country:US
Mailing Address - Phone:707-496-0167
Mailing Address - Fax:
Practice Address - Street 1:7895 EAST RIVER ROAD
Practice Address - Street 2:APT 201
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432
Practice Address - Country:US
Practice Address - Phone:707-496-0167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLCSW79751041C0700X
OR79751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical