Basic Information
| Provider Information | |||||||||
| NPI: | 1669519070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLMAN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2707 BROWNS LN | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709724961 | ||||||||
| FaxNumber: | 8709724088 | ||||||||
| Practice Location | |||||||||
| Address1: | 2707 BROWNS LN | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709724961 | ||||||||
| FaxNumber: | 8709724088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2005039215 | MO | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 490728003 | 05 | MO | MEDICAID |