1710222112 NPI number — MR. BRITON EDWARD HOLMBERG LCSW

Table of content: MR. BRITON EDWARD HOLMBERG LCSW (NPI 1710222112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710222112 NPI number — MR. BRITON EDWARD HOLMBERG LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLMBERG
Provider First Name:
BRITON
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1710222112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5732 N KENMORE AVE
Provider Second Line Business Mailing Address:
APT 1
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60660-6514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-368-0174
Provider Business Mailing Address Fax Number:
847-446-6957

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
690 OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINNETKA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60093-2522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-446-6955
Provider Business Practice Location Address Fax Number:
847-446-6957
Provider Enumeration Date:
12/11/2012

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: 1041C0700X , with the licence number:  149.015325 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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