Provider Demographics
NPI:1063123677
Name:HOLMES, MAX (LSW)
Entity type:Individual
Prefix:MR
First Name:MAX
Middle Name:
Last Name:HOLMES
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 N COUNTY ROAD 2050 E
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:IL
Mailing Address - Zip Code:62321-3551
Mailing Address - Country:US
Mailing Address - Phone:217-357-2173
Mailing Address - Fax:
Practice Address - Street 1:1450 N COUNTY ROAD 2050 E
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321-3551
Practice Address - Country:US
Practice Address - Phone:217-357-2173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL15016082104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker