Provider Demographics
NPI:1912174715
Name:HOLMES, THOMAS RAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RAY
Last Name:HOLMES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2923 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-5534
Mailing Address - Country:US
Mailing Address - Phone:269-330-4267
Mailing Address - Fax:
Practice Address - Street 1:2923 MEMORY LN
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-5534
Practice Address - Country:US
Practice Address - Phone:269-330-4267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002715103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68-0-C91213-0OtherBCBS
MI11391590OtherCAQH