Provider Demographics
NPI:1023200144
Name:LUNDBERG, TASHIE RENAE
Entity Type:Individual
Prefix:MRS
First Name:TASHIE
Middle Name:RENAE
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LOVELL
Mailing Address - State:WY
Mailing Address - Zip Code:82431-1947
Mailing Address - Country:US
Mailing Address - Phone:307-548-6722
Mailing Address - Fax:307-548-6700
Practice Address - Street 1:435 E 5TH ST
Practice Address - Street 2:
Practice Address - City:LOVELL
Practice Address - State:WY
Practice Address - Zip Code:82431-1947
Practice Address - Country:US
Practice Address - Phone:307-548-6722
Practice Address - Fax:307-548-6700
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-403235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY12027059OtherASHA
WY1770688871Medicaid
WYSP-403OtherSLP LICENSE