Provider Demographics
NPI:1841526084
Name:HOLMSTROM, ANTONIE (PLMHP)
Entity type:Individual
Prefix:
First Name:ANTONIE
Middle Name:
Last Name:HOLMSTROM
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8922 CUMING ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2732
Mailing Address - Country:US
Mailing Address - Phone:402-926-4373
Mailing Address - Fax:402-926-3898
Practice Address - Street 1:2501 CAPEHART RD
Practice Address - Street 2:
Practice Address - City:OFFUTT AFB
Practice Address - State:NE
Practice Address - Zip Code:68113-1043
Practice Address - Country:US
Practice Address - Phone:402-232-2307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3464101YM0800X
NE30281041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE7869OtherSTATE OF NEBRASKA