Provider Demographics
NPI:1023382769
Name:LUNDGREN, TIMOTHY ALAN (LPT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALAN
Last Name:LUNDGREN
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 GAILLARD ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3827
Mailing Address - Country:US
Mailing Address - Phone:909-217-8871
Mailing Address - Fax:
Practice Address - Street 1:1020 S ARROYO PKWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3911
Practice Address - Country:US
Practice Address - Phone:626-294-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36282167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician