Provider Demographics
NPI:1689130288
Name:HOLT, SHAKORA (LPT)
Entity Type:Individual
Prefix:
First Name:SHAKORA
Middle Name:
Last Name:HOLT
Suffix:
Gender:F
Credentials:LPT
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 15408
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-5408
Mailing Address - Country:US
Mailing Address - Phone:805-540-6500
Mailing Address - Fax:805-540-6501
Practice Address - Street 1:784 HIGH ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5243
Practice Address - Country:US
Practice Address - Phone:805-540-6500
Practice Address - Fax:805-540-6501
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34742167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician