Provider Demographics
NPI:1689976557
Name:HOLTBERG, TOMAS L (MA, LPC)
Entity Type:Individual
Prefix:
First Name:TOMAS
Middle Name:L
Last Name:HOLTBERG
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 86370
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6370
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:605-322-6475
Practice Address - Street 1:4400 W 69TH ST
Practice Address - Street 2:STE. 1500
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8171
Practice Address - Country:US
Practice Address - Phone:605-322-5700
Practice Address - Fax:605-322-5704
Is Sole Proprietor?:No
Enumeration Date:2010-11-29
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC7109101YP2500X
SD2209101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689976557OtherWELLMARK BCBS SD
SD6577202Medicaid
1689976557OtherTRICARE
SD2001602Medicaid