Provider Demographics
NPI:1417316365
Name:HOLT, MIRANDA (COTA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:HOLT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 PIEDMONT PL
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-5084
Mailing Address - Country:US
Mailing Address - Phone:318-537-3975
Mailing Address - Fax:
Practice Address - Street 1:1575 7TH AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-3704
Practice Address - Country:US
Practice Address - Phone:877-366-2580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-21
Last Update Date:2016-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2444282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital