Provider Demographics
NPI:1780342345
Name:HOLUB, LES JAY (RPH)
Entity type:Individual
Prefix:MR
First Name:LES
Middle Name:JAY
Last Name:HOLUB
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 SUNRISE TRL
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-4409
Mailing Address - Country:US
Mailing Address - Phone:928-201-5374
Mailing Address - Fax:
Practice Address - Street 1:4823 S HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-8314
Practice Address - Country:US
Practice Address - Phone:928-704-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS012947101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD01684094OtherDRIVERS LICENSE