MEDICARE: MRS. MARY HOLMES ST

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	235Z00000X	Speech-Language Pathologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12431	OTHER	NC	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306892641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY HOLMES ST

Provider Business Mailing Address
First Line	:	2316 ANDERSON DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27608-1404
Country	:	US
Telephone Number	:	919-781-5728
Fax Number	:	919-781-5744

Provider Business Practice Location Address
First Line	:	2316 ANDERSON DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27608-1404
Country	:	US
Telephone Number	:	919-781-5728
Fax Number	:	919-781-5744

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

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	10/06/2014

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Directions to “ MRS. MARY HOLMES ST” Practice Location

Language	Start Address	Practice Location

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