Provider Demographics
NPI:1881984573
Name:SUSITNA MARITAL COUNSELING
Entity type:Organization
Organization Name:SUSITNA MARITAL COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:907-351-3223
Mailing Address - Street 1:2600 DENALI ST STE 606
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2754
Mailing Address - Country:US
Mailing Address - Phone:907-351-3223
Mailing Address - Fax:907-272-9726
Practice Address - Street 1:2600 DENALI ST STE 606
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2754
Practice Address - Country:US
Practice Address - Phone:907-351-3223
Practice Address - Fax:907-272-9726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKLMFT 26106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty