Provider Demographics
NPI:1659475960
Name:HOLMES, MICHAEL S (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:HOLMES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-3732
Mailing Address - Country:US
Mailing Address - Phone:321-652-2643
Mailing Address - Fax:
Practice Address - Street 1:7341 OFFICE PARK PL STE 102
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8280
Practice Address - Country:US
Practice Address - Phone:321-690-6612
Practice Address - Fax:321-690-2630
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009015225100000X
FLPT33131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33131OtherFLORIDA STATE LICENSE
MIVAD000Medicaid