Basic Information
Provider Information | |||||||||
NPI: | 1710204987 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLMES | ||||||||
FirstName: | PATRICE | ||||||||
MiddleName: | JANELL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 103 S MAIN ST | ||||||||
Address2: | CENTER FOR BEHAVIORAL HEALTH OUTPATIENT | ||||||||
City: | MIDDLETOWN | ||||||||
State: | CT | ||||||||
PostalCode: | 064573651 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8603588760 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 103 S MAIN ST | ||||||||
Address2: | CENTER FOR BEHAVIORAL HEALTH OUTPATIENT | ||||||||
City: | MIDDLETOWN | ||||||||
State: | CT | ||||||||
PostalCode: | 064573651 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8603588760 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2010 | ||||||||
LastUpdateDate: | 08/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | LL32908 | SC | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2084P0800X | MTL000406 | DC | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 1.053250 | CT | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.