Healthcare Provider Details

I. General information

NPI: 1487590410
Provider Name (Legal Business Name): JEREMY RANDAL COREY HOLT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14040 N CAVE CREEK RD FL 3
PHOENIX AZ
85022-6117
US

IV. Provider business mailing address

610 E BELL RD STE 2-229
PHOENIX AZ
85022-2397
US

V. Phone/Fax

Practice location:
  • Phone: 480-292-9411
  • Fax:
Mailing address:
  • Phone: 480-647-1643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: