Provider Demographics
NPI:1386073138
Name:HOLTSCLAW, KIMBERLY
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:HOLTSCLAW
Suffix:
Gender:F
Credentials:
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 3102
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-0102
Mailing Address - Country:US
Mailing Address - Phone:732-261-6787
Mailing Address - Fax:
Practice Address - Street 1:2000 PENNINGTON ROAD
Practice Address - Street 2:FORCINA HALL 413-414
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08618
Practice Address - Country:US
Practice Address - Phone:732-261-6787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00122700101Y00000X
PAPC007817101YP2500X
NJ37PC00515400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor