Provider Demographics
NPI:1881006146
Name:HOLT, BRADLEY WARREN (MSW, LMSW)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:WARREN
Last Name:HOLT
Suffix:
Gender:M
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1971 W MARTEN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4670
Mailing Address - Country:US
Mailing Address - Phone:208-724-6460
Mailing Address - Fax:
Practice Address - Street 1:323 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5014
Practice Address - Country:US
Practice Address - Phone:208-463-0212
Practice Address - Fax:208-461-5452
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-33841104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLMSW-33841OtherSTATE OF IDAHO, OFFICE OF OCCUPATIONAL LICENSES, STATE BOARD OF SOCIAL WORK