Basic Information
| Provider Information | |||||||||
| NPI: | 1689976557 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLTBERG | ||||||||
| FirstName: | TOMAS | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 86370 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571186370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227510 | ||||||||
| FaxNumber: | 6053226475 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 W 69TH ST | ||||||||
| Address2: | STE. 1500 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571088171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053225700 | ||||||||
| FaxNumber: | 6053225704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2010 | ||||||||
| LastUpdateDate: | 10/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC7109 | SD | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 2209 | SD | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1689976557 | 01 | WELLMARK BCBS SD | OTHER | 6577202 | 05 | SD | MEDICAID | 1689976557 | 01 | TRICARE | OTHER | 2001602 | 05 | SD | MEDICAID |