Provider Demographics
NPI:1114010766
Name:HOLTGRAVES, MARNELL MAKELA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARNELL
Middle Name:MAKELA
Last Name:HOLTGRAVES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 EAST C. R. 300 NORTH
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362
Mailing Address - Country:US
Mailing Address - Phone:765-529-5226
Mailing Address - Fax:765-529-1556
Practice Address - Street 1:212 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362-4215
Practice Address - Country:US
Practice Address - Phone:765-529-5226
Practice Address - Fax:765-529-1556
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040702A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200038170AMedicaid
IN200038170AMedicaid