Healthcare Provider Details

I. General information

NPI: 1417444712
Provider Name (Legal Business Name): GLENN HOLT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 4TH AVE
BAY SHORE NY
11706-7908
US

IV. Provider business mailing address

203 GIBBS POND RD
NESCONSET NY
11767-2265
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-6707
  • Fax: 631-665-3564
Mailing address:
  • Phone: 508-692-8780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number102694-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: