Healthcare Provider Details

I. General information

NPI: 1053997304
Provider Name (Legal Business Name): IDA MARIE HOLDAHL MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 SHINGLE CREEK PKWY
BROOKLYN CENTER MN
55430-2322
US

IV. Provider business mailing address

5910 SHINGLE CREEK PKWY
BROOKLYN CENTER MN
55430-2322
US

V. Phone/Fax

Practice location:
  • Phone: 763-569-5228
  • Fax: 763-569-5240
Mailing address:
  • Phone: 763-569-5228
  • Fax: 763-569-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2754
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: