Provider Demographics
NPI:1558472183
Name:HOLMES, LARRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:HOLMES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1309
Mailing Address - Street 2:
Mailing Address - City:ARBOR VITAE
Mailing Address - State:WI
Mailing Address - Zip Code:54568-1309
Mailing Address - Country:US
Mailing Address - Phone:715-358-5400
Mailing Address - Fax:715-358-5405
Practice Address - Street 1:11102 TUCKAWAY RD
Practice Address - Street 2:
Practice Address - City:ARBOR VITAE
Practice Address - State:WI
Practice Address - Zip Code:54568-8913
Practice Address - Country:US
Practice Address - Phone:715-358-5400
Practice Address - Fax:715-358-5405
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2535103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI1253OtherMEDICARE PTAN
WI39148300Medicaid
WIP77300Medicare UPIN