Provider Demographics
NPI:1578769402
Name:HOLMAN, THERESA JOLENE (RADS)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:JOLENE
Last Name:HOLMAN
Suffix:
Gender:F
Credentials:RADS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3556 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-2532
Mailing Address - Country:US
Mailing Address - Phone:805-461-6157
Mailing Address - Fax:
Practice Address - Street 1:3556 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-2532
Practice Address - Country:US
Practice Address - Phone:805-461-6157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA400003BN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)