Provider Demographics
NPI:1992962252
Name:HOLMBERG, KRISTIN SIMONS (LCSW)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:SIMONS
Last Name:HOLMBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KRISTIN
Other - Middle Name:LYNN
Other - Last Name:SIMONS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:497 SW CENTURY DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1167
Mailing Address - Country:US
Mailing Address - Phone:458-292-9972
Mailing Address - Fax:541-318-0058
Practice Address - Street 1:2542 COURTNEY DRIVE
Practice Address - Street 2:ST. CHARLES BEHAVIORAL HEALTH
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-706-2768
Practice Address - Fax:541-706-4760
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW 000095811041C0700X
ORL61241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical