MEDICARE: TOM G HOLT LPC LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	505	WI
2	101YM0800X	Mental Health Counselor	1242308	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487733762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOM G HOLT LPC LMFT

Provider Business Mailing Address
First Line	:	W156N8327 PILGRIM RD STE 302
Second Line	:
City	:	MENOMONEE FALLS
State	:	WI
Zip	:	53051-3776
Country	:	US
Telephone Number	:	262-251-1112
Fax Number	:	414-540-2171

Provider Business Practice Location Address
First Line	:	W156N8327 PILGRIM RD STE 302
Second Line	:
City	:	MENOMONEE FALLS
State	:	WI
Zip	:	53051-3776
Country	:	US
Telephone Number	:	262-251-1112
Fax Number	:	262-251-1113

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	11/14/2023

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