Provider Demographics
NPI:1730729633
Name:HOLMES, TINA MARIE (CRSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:HOLMES
Suffix:
Gender:F
Credentials:CRSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03581-1659
Mailing Address - Country:US
Mailing Address - Phone:603-752-2511
Mailing Address - Fax:
Practice Address - Street 1:123 MAIN ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:NH
Practice Address - Zip Code:03581-1659
Practice Address - Country:US
Practice Address - Phone:603-466-5190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0241251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health