Provider Demographics
NPI:1780075341
Name:HOLZER, JUSTIN DANIEL (MFT-I)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DANIEL
Last Name:HOLZER
Suffix:
Gender:M
Credentials:MFT-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5475 CANYON CREST DR APT 16
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6433
Mailing Address - Country:US
Mailing Address - Phone:909-936-0228
Mailing Address - Fax:
Practice Address - Street 1:224 W GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-3740
Practice Address - Country:US
Practice Address - Phone:951-318-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85077106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist