Provider Demographics
NPI:1801958897
Name:LINE, HOLLY JEAN (LPCC)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:JEAN
Last Name:LINE
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 1:31121 HILLSIDE PASS
Mailing Address - Street 2:
Mailing Address - City:BREEZY POINT
Mailing Address - State:MN
Mailing Address - Zip Code:56472-3820
Mailing Address - Country:US
Mailing Address - Phone:218-562-5804
Mailing Address - Fax:
Practice Address - Street 1:520 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2902
Practice Address - Country:US
Practice Address - Phone:218-829-3235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00002101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1044529OtherPREFERRED ONE
MN00N15LIOtherBLUE CROSS BLUE SHIELD
MN1801958897OtherUCARE
MN1801958897OtherHEALTH PARTNERS