Healthcare Provider Details

I. General information

NPI: 1972748952
Provider Name (Legal Business Name): NELSON JOHN HOLMBERG M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2008
Last Update Date: 10/30/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 OLD HIGHWAY 99 S RD
MT VERNON WA
98273
US

IV. Provider business mailing address

4526 FEDERAL AVE BLDG 1
EVERETT WA
98203-2132
US

V. Phone/Fax

Practice location:
  • Phone: 360-542-8810
  • Fax: 360-542-8811
Mailing address:
  • Phone: 425-349-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60136969
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: