Provider Demographics
NPI:1053755868
Name:HOLMES, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:HOLMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3622 GOVERNOR HARRIS DR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-9258
Mailing Address - Country:US
Mailing Address - Phone:918-312-0450
Mailing Address - Fax:
Practice Address - Street 1:1705 CRADDUCK RD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-9491
Practice Address - Country:US
Practice Address - Phone:580-310-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKJ081056657101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100744520DMedicaid
OK100744520BMedicaid