Provider Demographics
NPI:1447313911
Name:HOLMES, IMAC SORAYA REYNAGA (EDD MS LPC LCADC)
Entity type:Individual
Prefix:DR
First Name:IMAC
Middle Name:SORAYA REYNAGA
Last Name:HOLMES
Suffix:
Gender:F
Credentials:EDD MS LPC LCADC
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-522-9879
Mailing Address - Fax:928-522-9880
Practice Address - Street 1:300 S 6TH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMS
Practice Address - State:AZ
Practice Address - Zip Code:86046-0110
Practice Address - Country:US
Practice Address - Phone:928-635-4441
Practice Address - Fax:928-635-4403
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAPC004761101YP2500X
NJ37LC00163700101YA0400X
NJ37PC00398600101YP2500X
AZLPC-19884101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)