Provider Demographics
NPI:1861533556
Name:HOLT, DEBORA R (MED)
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:R
Last Name:HOLT
Suffix:
Gender:F
Credentials:MED
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 760
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-0121
Mailing Address - Country:US
Mailing Address - Phone:509-764-7474
Mailing Address - Fax:509-764-7480
Practice Address - Street 1:404 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1957
Practice Address - Country:US
Practice Address - Phone:509-764-7474
Practice Address - Fax:509-764-7480
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004897101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA601772853OtherUBI