Provider Demographics
NPI:1235649914
Name:HOLSTON, CECIL II (LSW)
Entity Type:Individual
Prefix:
First Name:CECIL
Middle Name:
Last Name:HOLSTON
Suffix:II
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 PORTSMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-4417
Mailing Address - Country:US
Mailing Address - Phone:419-279-0933
Mailing Address - Fax:
Practice Address - Street 1:2202 PORTSMOUTH AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-4417
Practice Address - Country:US
Practice Address - Phone:419-279-0933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
10004941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical