Provider Demographics
NPI:1720675705
Name:HOLT, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:HOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9101 LA CRESADA DR APT 1823
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-4041
Mailing Address - Country:US
Mailing Address - Phone:828-337-1469
Mailing Address - Fax:
Practice Address - Street 1:14058 BEE CAVE PKWY
Practice Address - Street 2:
Practice Address - City:BEE CAVES
Practice Address - State:TX
Practice Address - Zip Code:78738-7071
Practice Address - Country:US
Practice Address - Phone:512-872-8170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2145541225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant