Provider Demographics
NPI:1174287015
Name:HOLSTON, DUSTIN GENE (LSW)
Entity type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:GENE
Last Name:HOLSTON
Suffix:
Gender:M
Credentials:LSW
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 314
Mailing Address - Street 2:
Mailing Address - City:KINGS MILLS
Mailing Address - State:OH
Mailing Address - Zip Code:45034-0314
Mailing Address - Country:US
Mailing Address - Phone:513-594-9554
Mailing Address - Fax:
Practice Address - Street 1:5300 WINNESTE AVE # 45232
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45232-1133
Practice Address - Country:US
Practice Address - Phone:513-901-0429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1903469104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS.1903469OtherCOUNSELOR, SOCIAL WORKER & MFT BOARD