Provider Demographics
NPI:1427618768
Name:HOLMBERG, FREDRICK
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:
Last Name:HOLMBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 UNIVERSITY AVE S APT E40
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4976
Mailing Address - Country:US
Mailing Address - Phone:907-888-2970
Mailing Address - Fax:
Practice Address - Street 1:1729 UNIVERSITY AVE S APT E40
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4976
Practice Address - Country:US
Practice Address - Phone:907-888-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4485101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)