Provider Demographics
NPI:1639305220
Name:HOLT, CHARLIE (MSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:HOLT
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:R
Other - Last Name:HOLT
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1132
Practice Address - Country:US
Practice Address - Phone:253-968-1484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.11012561041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical