Provider Demographics
NPI:1679069819
Name:HOLTZCLAW, JOHN HAYDEN (AUD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:HAYDEN
Last Name:HOLTZCLAW
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 MEDICAL PKWY
Mailing Address - Street 2:STE 320
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1023
Mailing Address - Country:US
Mailing Address - Phone:512-454-0392
Mailing Address - Fax:512-454-1233
Practice Address - Street 1:1340 WONDER WORLD DR STE 4301
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7695
Practice Address - Country:US
Practice Address - Phone:855-547-8369
Practice Address - Fax:512-738-8396
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80958231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80958OtherTEXAS AUDIOLOGIST LICENSE