Provider Demographics
NPI:1689281792
Name:HOLMES, PATRICE L (MS ED, LSC)
Entity Type:Individual
Prefix:MISS
First Name:PATRICE
Middle Name:L
Last Name:HOLMES
Suffix:
Gender:F
Credentials:MS ED, LSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5433 N MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-4033
Mailing Address - Country:US
Mailing Address - Phone:317-258-4744
Mailing Address - Fax:
Practice Address - Street 1:12995 STAR DR
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-5982
Practice Address - Country:US
Practice Address - Phone:317-853-7514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10230509101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNEW APPLICANT