Provider Demographics
NPI:1972074300
Name:HOLMES, MICHAEL (COTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HOLMES
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:MICHAEL
Other - Last Name:HOLMES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:217 EAST ST APT 106
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-2975
Mailing Address - Country:US
Mailing Address - Phone:870-351-7820
Mailing Address - Fax:
Practice Address - Street 1:1311 N PECAN ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-2816
Practice Address - Country:US
Practice Address - Phone:870-523-9514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1301224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant