Provider Demographics
NPI:1629773866
Name:HOLT, LAILAH
Entity Type:Individual
Prefix:MS
First Name:LAILAH
Middle Name:
Last Name:HOLT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5632 S INDIANA AVE # 5632
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1298
Mailing Address - Country:US
Mailing Address - Phone:312-312-4818
Mailing Address - Fax:
Practice Address - Street 1:3319 N ELSTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5811
Practice Address - Country:US
Practice Address - Phone:312-733-0883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician