Provider Demographics
NPI:1770507550
Name:HOLM, PAMELA A (MPA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:HOLM
Suffix:
Gender:F
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:886 BRUNSWICK LN
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4023
Mailing Address - Country:US
Mailing Address - Phone:321-639-3275
Mailing Address - Fax:
Practice Address - Street 1:2565 JUDGE FRAN JAMIESON WAY
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-5998
Practice Address - Country:US
Practice Address - Phone:321-634-3688
Practice Address - Fax:321-504-0955
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL764975400Medicaid