1841637428 NPI number — STEPHANIE BACKOF HOLMES KINNARE PSYCHOLOGIST

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841637428 NPI number — STEPHANIE BACKOF HOLMES KINNARE PSYCHOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KINNARE
Provider First Name:
STEPHANIE
Provider Middle Name:
BACKOF HOLMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYCHOLOGIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLMES
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1841637428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 748519
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-8519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-376-3800
Provider Business Mailing Address Fax Number:
904-376-3998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13241 BARTRAM PARK BLVD UNIT 1901
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32258-5228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-376-3800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2013

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: 103T00000X , with the licence number:  PY8730 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 111168300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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