Provider Demographics
NPI:1740082973
Name:HOLMES, MAYA SHANKS
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:SHANKS
Last Name:HOLMES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 CEDARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-4692
Mailing Address - Country:US
Mailing Address - Phone:504-345-3229
Mailing Address - Fax:
Practice Address - Street 1:345 PARKWAY 575
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3897
Practice Address - Country:US
Practice Address - Phone:470-473-5920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-23-252189106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician