Provider Demographics
NPI:1720104193
Name:HOLT, SUSANNE JENNIFER (ND, MA)
Entity type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:JENNIFER
Last Name:HOLT
Suffix:
Gender:F
Credentials:ND, MA
Other - Prefix:DR
Other - First Name:SUSANNE
Other - Middle Name:JENNIFER
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ND, MA
Mailing Address - Street 1:20068 10TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-2111
Mailing Address - Country:US
Mailing Address - Phone:206-550-7016
Mailing Address - Fax:
Practice Address - Street 1:20068 10TH AVE NW
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98177-2111
Practice Address - Country:US
Practice Address - Phone:206-550-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001772363A00000X
101YM0800X
WANT 00000482175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8478042Medicaid