Healthcare Provider Details

I. General information

NPI: 1750269403
Provider Name (Legal Business Name): CHARISSE NIRVANNA HOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 HILLSIDE DR
GEORGETOWN KY
40324-2114
US

IV. Provider business mailing address

144 HILLSIDE DR
GEORGETOWN KY
40324-2114
US

V. Phone/Fax

Practice location:
  • Phone: 804-651-0116
  • Fax: 804-651-0116
Mailing address:
  • Phone: 804-651-0116
  • Fax: 804-651-0116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: