1629209242 NPI number — MRS. MELINDA R. LUNDGREEN MSW, LCSW

Table of content: MRS. MELINDA R. LUNDGREEN MSW, LCSW (NPI 1629209242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629209242 NPI number — MRS. MELINDA R. LUNDGREEN MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDGREEN
Provider First Name:
MELINDA
Provider Middle Name:
R.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LUNDGREEN
Provider Other First Name:
MINDY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1629209242
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
94 E PAGES LN
Provider Second Line Business Mailing Address:
#A
Provider Business Mailing Address City Name:
CENTERVILLE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84014-2216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-294-0578
Provider Business Mailing Address Fax Number:
801-298-2147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
94 E PAGES LN
Provider Second Line Business Practice Location Address:
#A
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84014-2216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-726-6467
Provider Business Practice Location Address Fax Number:
801-726-6467
Provider Enumeration Date:
07/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  7695616-3501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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