Provider Demographics
NPI:1841637428
Name:KINNARE, STEPHANIE BACKOF HOLMES (PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BACKOF HOLMES
Last Name:KINNARE
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:B
Other - Last Name:HOLMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12724 GRAN BAY PKWY W STE 410
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-9486
Mailing Address - Country:US
Mailing Address - Phone:904-574-5200
Mailing Address - Fax:
Practice Address - Street 1:12724 GRAN BAY PKWY W STE 410
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-9486
Practice Address - Country:US
Practice Address - Phone:904-574-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8730103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHS759ZMedicare PIN