Healthcare Provider Details

I. General information

NPI: 1083435309
Provider Name (Legal Business Name): LONNIE HOLMES SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2024
Last Update Date: 10/19/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

686 HUMBOLDT ST
RICHMOND CA
94805-1959
US

IV. Provider business mailing address

207 37TH ST
RICHMOND CA
94805-2105
US

V. Phone/Fax

Practice location:
  • Phone: 415-574-1213
  • Fax:
Mailing address:
  • Phone: 510-236-3388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number070052BP
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: