Provider Demographics
NPI:1609415355
Name:HOLT, JOHNNY LEE
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:LEE
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 1:3436 MARY ELDER RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5050
Mailing Address - Country:US
Mailing Address - Phone:360-528-2590
Mailing Address - Fax:
Practice Address - Street 1:3436 MARY ELDER RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5050
Practice Address - Country:US
Practice Address - Phone:360-528-2590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-29
Last Update Date:2019-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician