Provider Demographics
NPI:1962596023
Name:JUDITH A. HOLMES, PHD., P.C.
Entity type:Organization
Organization Name:JUDITH A. HOLMES, PHD., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-296-3442
Mailing Address - Street 1:1440 RENAISSANCE DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-296-3442
Mailing Address - Fax:847-296-3543
Practice Address - Street 1:1440 RENAISSANCE DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-296-3442
Practice Address - Fax:847-296-3543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004106103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01673546OtherBLUE SHIELD
IL208853Medicare ID - Type Unspecified
IL208853Medicare PIN
IL01673546OtherBLUE SHIELD