Provider Demographics
NPI:1487733762
Name:HOLT, TOM G (LPC LMFT)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:G
Last Name:HOLT
Suffix:
Gender:M
Credentials:LPC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W156N8327 PILGRIM RD STE 302
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3776
Mailing Address - Country:US
Mailing Address - Phone:262-251-1112
Mailing Address - Fax:414-540-2171
Practice Address - Street 1:W156N8327 PILGRIM RD STE 302
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3776
Practice Address - Country:US
Practice Address - Phone:262-251-1112
Practice Address - Fax:262-251-1113
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI505104100000X
WI1242308101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39607200Medicaid