Provider Demographics
NPI:1770061178
Name:HOLTHUS, LYLE ALLEN (SCHOOL PSYCHOLOGIST)
Entity type:Individual
Prefix:MR
First Name:LYLE
Middle Name:ALLEN
Last Name:HOLTHUS
Suffix:
Gender:M
Credentials:SCHOOL PSYCHOLOGIST
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2840 NW 2ND AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6692
Mailing Address - Country:US
Mailing Address - Phone:800-233-5976
Mailing Address - Fax:800-238-3365
Practice Address - Street 1:2840 NW 2ND AVE STE 104
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6692
Practice Address - Country:US
Practice Address - Phone:800-233-5976
Practice Address - Fax:800-238-3365
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1525226142103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool