1487602827 NPI number — MR. REGINALD WYNN HOLT MA, LCPC, LPC, CADC

Table of content: MR. REGINALD WYNN HOLT MA, LCPC, LPC, CADC (NPI 1487602827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487602827 NPI number — MR. REGINALD WYNN HOLT MA, LCPC, LPC, CADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLT
Provider First Name:
REGINALD
Provider Middle Name:
WYNN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA, LCPC, LPC, CADC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487602827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1824 RUTGER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63104-2944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-621-1334
Provider Business Mailing Address Fax Number:
618-343-6235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6201 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62062-6870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-343-6230
Provider Business Practice Location Address Fax Number:
618-343-6235
Provider Enumeration Date:
05/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  18612 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YM0800X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YP2500X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)