Provider Demographics
NPI:1205168986
Name:HOLTZ, DEITDRE A
Entity type:Individual
Prefix:
First Name:DEITDRE
Middle Name:A
Last Name:HOLTZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 CHADBOURNE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-9639
Mailing Address - Country:US
Mailing Address - Phone:707-372-9083
Mailing Address - Fax:
Practice Address - Street 1:480 CHADBOURNE RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-9639
Practice Address - Country:US
Practice Address - Phone:707-372-9083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2025-05-06
Deactivation Date:2011-12-16
Deactivation Code:
Reactivation Date:2017-02-07
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
A23468OtherCERTIFIED CRIMINAL JUSTICE SPECIALIST