Provider Demographics
NPI:1235441510
Name:HOLM, VERNON ALBERT
Entity Type:Individual
Prefix:MR
First Name:VERNON
Middle Name:ALBERT
Last Name:HOLM
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 1:323 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2029
Mailing Address - Country:US
Mailing Address - Phone:909-919-8081
Mailing Address - Fax:909-592-6897
Practice Address - Street 1:323 W 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2029
Practice Address - Country:US
Practice Address - Phone:909-919-8081
Practice Address - Fax:909-592-6897
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-02
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1367101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)