Healthcare Provider Details

I. General information

NPI: 1710204987
Provider Name (Legal Business Name): PATRICE JANELL HOLMES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S MAIN ST CENTER FOR BEHAVIORAL HEALTH OUTPATIENT
MIDDLETOWN CT
06457-3651
US

IV. Provider business mailing address

103 S MAIN ST CENTER FOR BEHAVIORAL HEALTH OUTPATIENT
MIDDLETOWN CT
06457-3651
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-8760
  • Fax:
Mailing address:
  • Phone: 860-358-8760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL32908
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMTL000406
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number1.053250
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: