Provider Demographics
NPI:1912052689
Name:VILTZ, PHYLLIS HOLT (SPE)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:HOLT
Last Name:VILTZ
Suffix:
Gender:F
Credentials:SPE
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:EDWINA
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1014 CHRISTOPHER LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37015-2823
Mailing Address - Country:US
Mailing Address - Phone:615-792-2836
Mailing Address - Fax:615-650-2929
Practice Address - Street 1:620 GALLATIN PIKE S
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4013
Practice Address - Country:US
Practice Address - Phone:615-460-4318
Practice Address - Fax:615-460-4308
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPE0000011569103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral