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NPI Code Detail

MEDICARE: DR. IMAC SORAYA REYNAGA HOLMES ED.D M.S. LPC LCADC

MEDICARE: DR. IMAC SORAYA REYNAGA HOLMES ED.D M.S. LPC LCADC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YP2500XProfessional CounselorPC004761PA
2101YA0400XAddiction (Substance Use Disorder) Counselor37LC00163700NJ
3101YP2500XProfessional Counselor37PC00398600NJ
4101YP2500XProfessional CounselorLPC-19884AZ

General Provider Information

NPI Number : 1447313911
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. IMAC SORAYA REYNAGA HOLMES ED.D M.S. LPC LCADC
Provider Business Mailing Address
First Line : PO BOX 3630
Second Line :
City : FLAGSTAFF
State : AZ
Zip : 86003-3630
Country : US
Telephone Number : 928-522-9879
Fax Number : 928-522-9880
Provider Business Practice Location Address
First Line : 300 S 6TH ST
Second Line :
City : WILLIAMS
State : AZ
Zip : 86046-0110
Country : US
Telephone Number : 928-635-4441
Fax Number : 928-635-4403
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/18/2006
Last Update Date : 07/21/2022

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