Provider Demographics
NPI:1952446387
Name:HOLMES, THEARTIS DOREISE (LCAS)
Entity Type:Individual
Prefix:MS
First Name:THEARTIS
Middle Name:DOREISE
Last Name:HOLMES
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6773 LEANING OAK RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-5206
Mailing Address - Country:US
Mailing Address - Phone:919-482-6382
Mailing Address - Fax:919-693-1982
Practice Address - Street 1:104 BELLE ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-3350
Practice Address - Country:US
Practice Address - Phone:919-603-9696
Practice Address - Fax:919-603-1565
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC924101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111820Medicaid