Provider Demographics
NPI:1013395417
Name:LUNDGREN, LEANNE (PT)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 S EL CAMINO REAL
Mailing Address - Street 2:#100
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6208
Mailing Address - Country:US
Mailing Address - Phone:760-681-5222
Mailing Address - Fax:760-681-5151
Practice Address - Street 1:2122 S EL CAMINO REAL
Practice Address - Street 2:#100
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6208
Practice Address - Country:US
Practice Address - Phone:760-681-5222
Practice Address - Fax:760-681-5151
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42507225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist