Healthcare Provider Details

I. General information

NPI: 1689976557
Provider Name (Legal Business Name): TOMAS L HOLTBERG MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 69TH ST STE. 1500
SIOUX FALLS SD
57108-8171
US

IV. Provider business mailing address

PO BOX 86370
SIOUX FALLS SD
57118-6370
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-5700
  • Fax: 605-322-5704
Mailing address:
  • Phone: 605-322-7510
  • Fax: 605-322-6475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2209
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC7109
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: