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General NPI Number Information
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NPI Number | 1720600547
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Entity Type | Individual
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Provider Name | HOLLY JUSTINE LASTINE LCSW, LICSW
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Gender | Female
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Dates
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Enumeration Date | 05/14/2020
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Last Update Date | 06/27/2023
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Provider Practice Location Address
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Address Line | 7895 EAST RIVER ROAD APT 201
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City | FRIDLEY
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State | MN
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Zip | 55432
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Country | US
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Telephone | 707-496-0167
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Fax |
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Provider Business Mailing Address
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Address Line | 7895 EAST RIVER ROAD APT 201
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City | FRIDLEY
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State | MN
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Zip | 55432
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Country | US
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Telephone | 707-496-0167
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW7975
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 7975
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License Number State | OR
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