Provider Demographics
NPI:1811472087
Name:HOLT, ODESSA (MSW)
Entity type:Individual
Prefix:
First Name:ODESSA
Middle Name:
Last Name:HOLT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 GREAT CEDAR SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH
Mailing Address - State:MA
Mailing Address - Zip Code:02769-2837
Mailing Address - Country:US
Mailing Address - Phone:617-821-3158
Mailing Address - Fax:
Practice Address - Street 1:1 HOPPIN ST STE 304
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4141
Practice Address - Country:US
Practice Address - Phone:401-444-3674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA113568-SW-LICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical