Healthcare Provider Details

I. General information

NPI: 1447313911
Provider Name (Legal Business Name): IMAC SORAYA REYNAGA HOLMES ED.D M.S. LPC LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/21/2022
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S 6TH ST
WILLIAMS AZ
86046-0110
US

IV. Provider business mailing address

PO BOX 3630
FLAGSTAFF AZ
86003-3630
US

V. Phone/Fax

Practice location:
  • Phone: 928-635-4441
  • Fax: 928-635-4403
Mailing address:
  • Phone: 928-522-9879
  • Fax: 928-522-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC004761
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00163700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00398600
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-19884
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: