Provider Demographics
NPI:1083363626
Name:HOLT, RYAN EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:EDWARD
Last Name:HOLT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16173 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-2485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1723 E SOUTHLAKE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6445
Practice Address - Country:US
Practice Address - Phone:682-292-7012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32870103T00000X
TX38271103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist