Provider Demographics
NPI:1013047018
Name:HOLMES, JUDITH A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:A
Last Name:HOLMES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1440 RENAISSANCE DR STE 220
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1452
Mailing Address - Country:US
Mailing Address - Phone:847-296-3442
Mailing Address - Fax:847-296-3543
Practice Address - Street 1:1440 RENAISSANCE DR STE 220
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1452
Practice Address - Country:US
Practice Address - Phone:847-296-3442
Practice Address - Fax:847-296-3543
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004106103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071004106Medicaid
IL071004106Medicaid