Provider Demographics
NPI:1902175631
Name:PENA HOLMES, HOLLIE M (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:HOLLIE
Middle Name:M
Last Name:PENA HOLMES
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6364 77TH PL
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-1306
Mailing Address - Country:US
Mailing Address - Phone:718-326-1436
Mailing Address - Fax:
Practice Address - Street 1:567 KINGSTON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1707
Practice Address - Country:US
Practice Address - Phone:718-498-2500
Practice Address - Fax:718-778-4018
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067505104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker