Provider Demographics
NPI:1629175039
Name:HOLTZ, FRED L (PHD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:L
Last Name:HOLTZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-0742
Mailing Address - Country:US
Mailing Address - Phone:631-427-6669
Mailing Address - Fax:631-427-6669
Practice Address - Street 1:20 BROADHOLLOW RD
Practice Address - Street 2:SUITE 2004
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-2501
Practice Address - Country:US
Practice Address - Phone:631-427-6669
Practice Address - Fax:631-427-6669
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010194-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV66761Medicare UPIN