Provider Demographics
NPI:1053045898
Name:HOLDAWAY, MARVON SHANE (CM)
Entity Type:Individual
Prefix:
First Name:MARVON
Middle Name:SHANE
Last Name:HOLDAWAY
Suffix:
Gender:M
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:UT
Mailing Address - Zip Code:84647-0031
Mailing Address - Country:US
Mailing Address - Phone:435-462-2781
Mailing Address - Fax:435-462-0155
Practice Address - Street 1:265 N STATE ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647-1108
Practice Address - Country:US
Practice Address - Phone:435-462-2781
Practice Address - Fax:435-462-0155
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTHT007021-001Medicaid