Provider Demographics
NPI:1972233369
Name:HOLT, DEREK (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:HOLT
Suffix:
Gender:M
Credentials:PMHNP-BC
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 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-327-3362
Mailing Address - Fax:406-327-3349
Practice Address - Street 1:900 N ORANGE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2998
Practice Address - Country:US
Practice Address - Phone:406-327-3362
Practice Address - Fax:406-327-3349
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-195627363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health