Provider Demographics
NPI:1144352162
Name:HOLMES, RUDOLPH (MA LIC SW)
Entity type:Individual
Prefix:MR
First Name:RUDOLPH
Middle Name:
Last Name:HOLMES
Suffix:
Gender:M
Credentials:MA LIC SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 THOMAS AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-2355
Mailing Address - Country:US
Mailing Address - Phone:612-251-5738
Mailing Address - Fax:
Practice Address - Street 1:2301 THOMAS AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-2355
Practice Address - Country:US
Practice Address - Phone:612-251-5738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8534104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN113136OtherHEALTHPARTNERS OF MN
MN3G739HOOtherBLUE CROSS BLUE SHIELD MN
MN8534OtherSTATE LICENSE