Provider Demographics
NPI:1417444712
Name:HOLT, GLENN
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:HOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 GIBBS POND RD
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-2265
Mailing Address - Country:US
Mailing Address - Phone:508-692-8780
Mailing Address - Fax:
Practice Address - Street 1:9 4TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7908
Practice Address - Country:US
Practice Address - Phone:631-665-6707
Practice Address - Fax:631-665-3564
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102694-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY102694-1OtherNY STATE LICENSE