Provider Demographics
NPI:1568506814
Name:HOLIFIELD, JAMES WALTER (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:WALTER
Last Name:HOLIFIELD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6944 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3923
Mailing Address - Country:US
Mailing Address - Phone:414-540-0808
Mailing Address - Fax:414-540-9408
Practice Address - Street 1:6944 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3923
Practice Address - Country:US
Practice Address - Phone:414-540-0808
Practice Address - Fax:414-540-9408
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3086-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39293200Medicaid