Provider Demographics
NPI:1285101139
Name:HOLMES, MATTHEW (SUPPORT COORDINATOR)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:HOLMES
Suffix:
Gender:M
Credentials:SUPPORT COORDINATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SHERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WESTAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-3731
Mailing Address - Country:US
Mailing Address - Phone:973-489-9820
Mailing Address - Fax:
Practice Address - Street 1:17 SHERWOOD LN
Practice Address - Street 2:
Practice Address - City:WESTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-3731
Practice Address - Country:US
Practice Address - Phone:973-489-9820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ83-2328337Medicaid