Provider Demographics
NPI:1063731974
Name:HOLT, CHARLES WAYNE (BA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WAYNE
Last Name:HOLT
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34731 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-9104
Mailing Address - Country:US
Mailing Address - Phone:918-647-4897
Mailing Address - Fax:
Practice Address - Street 1:1000 MEADOW LANE
Practice Address - Street 2:
Practice Address - City:HOWE
Practice Address - State:OK
Practice Address - Zip Code:74940
Practice Address - Country:US
Practice Address - Phone:918-658-2189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health