Provider Demographics
NPI:1922991892
Name:HOLT, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
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 1:2041 E WALLING CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-8464
Mailing Address - Country:US
Mailing Address - Phone:208-949-1415
Mailing Address - Fax:
Practice Address - Street 1:1087 E PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-369-9168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician