Basic Information
| Provider Information | |||||||||
| NPI: | 1326422916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLT | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BBM | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4232 S 24TH WEST AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741076725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183443168 | ||||||||
| FaxNumber: | 9188344189 | ||||||||
| Practice Location | |||||||||
| Address1: | 3507 E ADMIRAL PL | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741158211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188344194 | ||||||||
| FaxNumber: | 9188344189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2015 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 171R00000X | N | Other Service Providers | Interpreter |
No ID Information.