Provider Demographics
NPI:1730651142
Name:MARY T HOLCOMB PSYD LLC
Entity type:Organization
Organization Name:MARY T HOLCOMB PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARY T HOLCOMB
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:HOLCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:407-923-3927
Mailing Address - Street 1:914 KERSFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1936
Mailing Address - Country:US
Mailing Address - Phone:407-923-3927
Mailing Address - Fax:
Practice Address - Street 1:2700 WESTHALL LN STE 110
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7403
Practice Address - Country:US
Practice Address - Phone:407-475-1025
Practice Address - Fax:407-475-1027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-24
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1235154352OtherINDIVIDUAL NPI