Provider Demographics
NPI:1407943178
Name:HOLMES, EDNA FAYE
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:FAYE
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 1:5808 DEVERS DR
Mailing Address - Street 2:H
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46216-2137
Mailing Address - Country:US
Mailing Address - Phone:317-918-1921
Mailing Address - Fax:
Practice Address - Street 1:5808 DEVERS DR
Practice Address - Street 2:H
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-2137
Practice Address - Country:US
Practice Address - Phone:317-918-1921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530Medicaid
IN100270530Medicaid