Healthcare Provider Details

I. General information

NPI: 1942631577
Provider Name (Legal Business Name): FREDDIE ANTONIO HOLMES OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2013
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2743 CAPITAL CIR NE
TALLAHASSEE FL
32308-1114
US

IV. Provider business mailing address

PO BOX 12218
TALLAHASSEE FL
32317-2218
US

V. Phone/Fax

Practice location:
  • Phone: 850-725-5008
  • Fax: 850-383-0099
Mailing address:
  • Phone: 888-570-5538
  • Fax: 850-270-6892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number10740
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number10740
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: