1316748783 NPI number — DENEEN AMANDA HOLMES MA LPC NCC ALMFT LPN

Table of content: (NPI 1104912088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316748783 NPI number — DENEEN AMANDA HOLMES MA LPC NCC ALMFT LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLMES
Provider First Name:
DENEEN
Provider Middle Name:
AMANDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA LPC NCC ALMFT LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316748783
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4820 179TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COUNTRY CLUB HILLS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60478-2918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-833-9298
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19624 GOVERNORS HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOSSMOOR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60422-2092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
872-225-6010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2025

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  208.001188 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 164W00000X , with the licence number: 043.116761 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 178.019884 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)