Provider Demographics
NPI:1972888113
Name:OMHOLT, MADISON (PHD, LMFT, SEP)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:OMHOLT
Suffix:
Gender:M
Credentials:PHD, LMFT, SEP
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 632951
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-2951
Mailing Address - Country:US
Mailing Address - Phone:619-519-1000
Mailing Address - Fax:
Practice Address - Street 1:131 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3021
Practice Address - Country:US
Practice Address - Phone:619-519-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50577106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist