Provider Demographics
NPI:1063628485
Name:LUNDBERG, GARY BARLOW (MA - LMFT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:BARLOW
Last Name:LUNDBERG
Suffix:
Gender:M
Credentials:MA - LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3680 LITTLE ROCK DR
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5261
Mailing Address - Country:US
Mailing Address - Phone:801-224-3447
Mailing Address - Fax:800-122-4345
Practice Address - Street 1:3680 LITTLE ROCK DR
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5261
Practice Address - Country:US
Practice Address - Phone:801-224-3447
Practice Address - Fax:800-122-4345
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT115477-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist