Healthcare Provider Details

I. General information

NPI: 1578836318
Provider Name (Legal Business Name): JONATHAN CARL HOLMES LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 SUMMER ST
HAVERHILL MA
01830-5814
US

IV. Provider business mailing address

310 CODMAN HILL RD APT D #1
BOXBOROUGH MA
01719-1727
US

V. Phone/Fax

Practice location:
  • Phone: 978-373-8222
  • Fax:
Mailing address:
  • Phone: 617-908-6848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114979
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: