Healthcare Provider Details

I. General information

NPI: 1639302490
Provider Name (Legal Business Name): SHANEKA HOLMES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 ROBESON ST
FAYETTEVILLE NC
28301-5635
US

IV. Provider business mailing address

PO BOX 970
HOPE MILLS NC
28348-0970
US

V. Phone/Fax

Practice location:
  • Phone: 910-286-3424
  • Fax:
Mailing address:
  • Phone: 910-286-3424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21999
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP008933
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License NumberA-3745
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number098724
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: