Provider Demographics
NPI:1295268456
Name:HOLMES, BRUCE BENNETT (MA, LSW)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:BENNETT
Last Name:HOLMES
Suffix:
Gender:M
Credentials:MA, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21315 FAIRMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4805
Mailing Address - Country:US
Mailing Address - Phone:216-618-5029
Mailing Address - Fax:216-371-0480
Practice Address - Street 1:24100 CHAGRIN BLVD STE 330
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5552
Practice Address - Country:US
Practice Address - Phone:800-642-4560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS 0800638101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health