Provider Demographics
NPI:1538472634
Name:HOLMBERG, MATTHEW ROBERT (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:HOLMBERG
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 LELARAY ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2220
Mailing Address - Country:US
Mailing Address - Phone:719-475-0477
Mailing Address - Fax:
Practice Address - Street 1:2210 LELARAY ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2220
Practice Address - Country:US
Practice Address - Phone:719-475-0477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-17
Last Update Date:2010-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 18305235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist