Provider Demographics
NPI:1104048982
Name:HOLSTON, RICHARD G (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:HOLSTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1369
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-1369
Mailing Address - Country:US
Mailing Address - Phone:707-939-9921
Mailing Address - Fax:707-939-9931
Practice Address - Street 1:1731 N OAK ST
Practice Address - Street 2:
Practice Address - City:CALISTOGA
Practice Address - State:CA
Practice Address - Zip Code:94515-1118
Practice Address - Country:US
Practice Address - Phone:707-939-9921
Practice Address - Fax:707-939-9931
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPL60530102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL60531Medicaid
CA00PL60530Medicare PIN