Provider Demographics
NPI:1851154637
Name:HOLMES, DASHAVONE (LMBT)
Entity Type:Individual
Prefix:
First Name:DASHAVONE
Middle Name:
Last Name:HOLMES
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-3238
Mailing Address - Country:US
Mailing Address - Phone:910-835-6275
Mailing Address - Fax:
Practice Address - Street 1:757 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3238
Practice Address - Country:US
Practice Address - Phone:910-390-0107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21295225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist