Healthcare Provider Details

I. General information

NPI: 1417031337
Provider Name (Legal Business Name): RICHARD DANE HOLT LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 WEST TWENTY FIRST
CLOVIS NM
88101
US

IV. Provider business mailing address

279 SOUTH ROOSEVELT ROAD X
PORTALES NM
88130
US

V. Phone/Fax

Practice location:
  • Phone: 505-769-2345
  • Fax: 505-769-8974
Mailing address:
  • Phone: 505-359-3137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM05987
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: