Provider Demographics
NPI:1619859840
Name:HOLMES, TANIJAH KREVONDRA
Entity type:Individual
Prefix:
First Name:TANIJAH
Middle Name:KREVONDRA
Last Name:HOLMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8631 NEUSE CLUB LN APT 111
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8039
Mailing Address - Country:US
Mailing Address - Phone:984-301-3679
Mailing Address - Fax:
Practice Address - Street 1:3610 BUSH ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7511
Practice Address - Country:US
Practice Address - Phone:984-204-1233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-21
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician