Healthcare Provider Details

I. General information

NPI: 1609276260
Provider Name (Legal Business Name): SARA JULSRUD HOLTMAN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2014
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 AMERICAN BLVD E STE 8
BLOOMINGTON MN
55425-1230
US

IV. Provider business mailing address

26822 LOFTON AVE
CHISAGO CITY MN
55013-9759
US

V. Phone/Fax

Practice location:
  • Phone: 952-767-2267
  • Fax:
Mailing address:
  • Phone: 701-330-5211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60511087
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP6830
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: