Provider Demographics
NPI:1164164786
Name:HOLTON, GAYLE HALL
Entity Type:Individual
Prefix:MRS
First Name:GAYLE
Middle Name:HALL
Last Name:HOLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 SHAMROCK CT
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5337
Mailing Address - Country:US
Mailing Address - Phone:228-497-0690
Mailing Address - Fax:228-497-1363
Practice Address - Street 1:3407 SHAMROCK CT
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5337
Practice Address - Country:US
Practice Address - Phone:228-497-0690
Practice Address - Fax:228-497-1363
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid