Provider Demographics
NPI:1114462603
Name:HOLMES, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HOLMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 BERTRAND DR
Mailing Address - Street 2:BUITE B2
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-9107
Mailing Address - Country:US
Mailing Address - Phone:337-319-1315
Mailing Address - Fax:
Practice Address - Street 1:1304 BERTRAND DR
Practice Address - Street 2:BUITE B2
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-9107
Practice Address - Country:US
Practice Address - Phone:337-319-1315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health