Provider Demographics
NPI:1629558580
Name:HOLDREN, MICHAEL E (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:HOLDREN
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 1:12 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:CAZENOVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13035-1026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 GREEN ST
Practice Address - Street 2:
Practice Address - City:CAZENOVIA
Practice Address - State:NY
Practice Address - Zip Code:13035-1026
Practice Address - Country:US
Practice Address - Phone:315-412-6609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017166103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist