Provider Demographics
NPI:1720532823
Name:HOLEM, IDA (MS)
Entity Type:Individual
Prefix:MRS
First Name:IDA
Middle Name:
Last Name:HOLEM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 HALCYON LN
Mailing Address - Street 2:603
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-6689
Mailing Address - Country:US
Mailing Address - Phone:904-302-5340
Mailing Address - Fax:
Practice Address - Street 1:2950 HALCYON LN
Practice Address - Street 2:603
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-6689
Practice Address - Country:US
Practice Address - Phone:904-302-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health