Healthcare Provider Details

I. General information

NPI: 1295040988
Provider Name (Legal Business Name): CASEY A HOLTZ PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17100 W NORTH AVE SUITE 100
BROOKFIELD WI
53005-4436
US

IV. Provider business mailing address

17100 W NORTH AVE SUITE 100
BROOKFIELD WI
53005-4436
US

V. Phone/Fax

Practice location:
  • Phone: 262-786-9184
  • Fax: 262-786-1906
Mailing address:
  • Phone: 414-810-7647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number594-226
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4444-125
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2962-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: