Provider Demographics
NPI:1780809475
Name:HOLT, BRENT MARION
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:MARION
Last Name:HOLT
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 1:5030 N TORTOLITA RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-9486
Mailing Address - Country:US
Mailing Address - Phone:520-975-5797
Mailing Address - Fax:
Practice Address - Street 1:1010 E 10TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-5813
Practice Address - Country:US
Practice Address - Phone:520-225-6410
Practice Address - Fax:520-225-6170
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ595598Medicaid