Provider Demographics
NPI:1881182350
Name:ESPY HOLTZCLAW, MISTY COLLEEN (CADC11)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:COLLEEN
Last Name:ESPY HOLTZCLAW
Suffix:
Gender:F
Credentials:CADC11
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 NW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1525
Mailing Address - Country:US
Mailing Address - Phone:541-955-9227
Mailing Address - Fax:
Practice Address - Street 1:806 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1525
Practice Address - Country:US
Practice Address - Phone:541-955-9227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR92-07-20294101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty