Provider Demographics
NPI:1235154352
Name:HOLCOMB, MARY T
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:T
Last Name:HOLCOMB
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 WESTHALL LN STE 110
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7403
Mailing Address - Country:US
Mailing Address - Phone:407-475-1025
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:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4613103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59488OtherBLUE CROSS BLUE SHIELD
FL59488WMedicare ID - Type UnspecifiedLAKE COUNTIES
FL59488OtherBLUE CROSS BLUE SHIELD