Healthcare Provider Details

I. General information

NPI: 1043753031
Provider Name (Legal Business Name): KEITH R HOLDER CMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2016
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E. 300 N.
GUNNISON UT
84634-0550
US

IV. Provider business mailing address

PO BOX 220460
CENTERFIELD UT
84622-0460
US

V. Phone/Fax

Practice location:
  • Phone: 435-528-6000
  • Fax:
Mailing address:
  • Phone: 435-340-0905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10124360-6004
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: