Provider Demographics
NPI:1154333938
Name:HOLBROOK, MISTI MARIE (LPP)
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:MARIE
Last Name:HOLBROOK
Suffix:
Gender:F
Credentials:LPP
Other - Prefix:
Other - First Name:MISTI
Other - Middle Name:
Other - Last Name:PENCE-JUSTICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:321 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1671
Practice Address - Country:US
Practice Address - Phone:606-784-4161
Practice Address - Fax:606-783-9952
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY115956103TC0700X
KY0113103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11717037OtherCAQH
000000226450 NONPAROtherANTHEM BCBS
KY7100283710Medicaid
9488279OtherAETNA
KY7100283710Medicaid