Provider Demographics
NPI:1720964976
Name:HOLMBERG, LUCIEN
Entity type:Individual
Prefix:
First Name:LUCIEN
Middle Name:
Last Name:HOLMBERG
Suffix:
Gender:X
Credentials:
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 718713
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8713
Mailing Address - Country:US
Mailing Address - Phone:317-502-3512
Mailing Address - Fax:
Practice Address - Street 1:11530 ALLISONVILLE RD STE 100
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-1862
Practice Address - Country:US
Practice Address - Phone:317-742-9730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-24-380125106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician