Healthcare Provider Details

I. General information

NPI: 1487733762
Provider Name (Legal Business Name): TOM G HOLT LPC LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W156N8327 PILGRIM RD STE 302
MENOMONEE FALLS WI
53051-3776
US

IV. Provider business mailing address

W156N8327 PILGRIM RD STE 302
MENOMONEE FALLS WI
53051-3776
US

V. Phone/Fax

Practice location:
  • Phone: 262-251-1112
  • Fax: 262-251-1113
Mailing address:
  • Phone: 262-251-1112
  • Fax: 414-540-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number505
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1242308
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: