Provider Demographics
NPI:1578696654
Name:HOLTON, GRESHAM ROYAL (PHD,LMFT)
Entity Type:Individual
Prefix:DR
First Name:GRESHAM
Middle Name:ROYAL
Last Name:HOLTON
Suffix:
Gender:M
Credentials:PHD,LMFT
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:KLIMKO
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:MS, LMFT
Mailing Address - Street 1:3543 RAINTREE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-2147
Mailing Address - Country:US
Mailing Address - Phone:229-559-6389
Mailing Address - Fax:229-559-7760
Practice Address - Street 1:3757 JOHNSTON RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-2105
Practice Address - Country:US
Practice Address - Phone:229-559-5944
Practice Address - Fax:229-559-7760
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000396106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist