Provider Demographics
NPI:1790861664
Name:HOLMES, EUGENE PAUL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:PAUL
Last Name:HOLMES
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 747
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-1125
Mailing Address - Country:US
Mailing Address - Phone:708-403-7570
Mailing Address - Fax:708-403-7546
Practice Address - Street 1:1800 RAVINIA PL
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3761
Practice Address - Country:US
Practice Address - Phone:708-403-7570
Practice Address - Fax:708-403-7546
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005108103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL279826000OtherMAGELLAN HEALTH SERVICES
IL01634764OtherBCBSIL
IL210273Medicare ID - Type UnspecifiedMEDICARE PART B