Provider Demographics
NPI:1033291372
Name:LUNDQUIST, MARK A (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:LUNDQUIST
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 2ND ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-2038
Mailing Address - Country:US
Mailing Address - Phone:315-868-8610
Mailing Address - Fax:
Practice Address - Street 1:178 2ND ST
Practice Address - Street 2:SUITE 2
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-2038
Practice Address - Country:US
Practice Address - Phone:315-868-8610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR042820-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical