Basic Information
| Provider Information | |||||||||
| NPI: | 1467546697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLT | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2120 EXCHANGE ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033250241 | ||||||||
| FaxNumber: | 5033258483 | ||||||||
| Practice Location | |||||||||
| Address1: | 2120 EXCHANGE ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033250241 | ||||||||
| FaxNumber: | 5033258483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 091007020N6 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 084918 | 05 | OR | MEDICAID |