Provider Demographics
NPI:1114277225
Name:HOLMES, TRAVIS S (MHC)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:S
Last Name:HOLMES
Suffix:
Gender:M
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4943
Mailing Address - Country:US
Mailing Address - Phone:803-775-9364
Mailing Address - Fax:803-773-6615
Practice Address - Street 1:2244 BROWNTOWN RD
Practice Address - Street 2:
Practice Address - City:BISHOPVILLE
Practice Address - State:SC
Practice Address - Zip Code:29010-9664
Practice Address - Country:US
Practice Address - Phone:803-428-6052
Practice Address - Fax:803-428-5407
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC457633Medicaid