Provider Demographics
NPI:1841637428
Name:KINNARE, STEPHANIE BACKOF HOLMES (PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BACKOF HOLMES
Last Name:KINNARE
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:B
Other - Last Name:HOLMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 748519
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8519
Mailing Address - Country:US
Mailing Address - Phone:904-376-3800
Mailing Address - Fax:904-376-3998
Practice Address - Street 1:13241 BARTRAM PARK BLVD UNIT 1901
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5228
Practice Address - Country:US
Practice Address - Phone:904-376-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8730103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHS759ZMedicare PIN