1689976557 NPI number — TOMAS L HOLTBERG MA, LPC

Table of content: TOMAS L HOLTBERG MA, LPC (NPI 1689976557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689976557 NPI number — TOMAS L HOLTBERG MA, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLTBERG
Provider First Name:
TOMAS
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689976557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 86370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57118-6370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-7510
Provider Business Mailing Address Fax Number:
605-322-6475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 W 69TH ST
Provider Second Line Business Practice Location Address:
STE. 1500
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57108-8171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-5700
Provider Business Practice Location Address Fax Number:
605-322-5704
Provider Enumeration Date:
11/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC7109 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 2209 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1689976557 . This is a "WELLMARK BCBS SD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6577202 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1689976557 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2001602 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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