Basic Information
| Provider Information | |||||||||
| NPI: | 1447313911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | IMAC | ||||||||
| MiddleName: | SORAYA REYNAGA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ED.D M.S. LPC LCADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3630 | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860033630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285229879 | ||||||||
| FaxNumber: | 9285229880 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860460110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286354441 | ||||||||
| FaxNumber: | 9286354403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PC004761 | PA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 37LC00163700 | NJ | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 37PC00398600 | NJ | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | LPC-19884 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.