Provider Demographics
NPI:1356372031
Name:HOLTZ, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:HOLTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 PLYMOUTH RD STE 308
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1640
Mailing Address - Country:US
Mailing Address - Phone:610-825-9400
Mailing Address - Fax:610-825-7130
Practice Address - Street 1:525 PLYMOUTH RD STE 308
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1640
Practice Address - Country:US
Practice Address - Phone:610-825-9400
Practice Address - Fax:610-825-7130
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW012946103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA066528Medicare ID - Type Unspecified