MEDICARE: MS. BRENDA FAY HOLMES MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013266576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BRENDA FAY HOLMES MS

Provider Business Mailing Address
First Line	:	2632 SW PORT ST LUCIE BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-2845
Country	:	US
Telephone Number	:	561-616-8411
Fax Number	:	561-616-8412

Provider Business Practice Location Address
First Line	:	2632 SW PORT ST LUCIE BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-2845
Country	:	US
Telephone Number	:	561-616-8411
Fax Number	:	561-616-8412

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2012
Last Update Date	:	11/26/2019

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