Provider Demographics
NPI:1083747232
Name:LUNDBLAD, DANIEL CHARLES (LMSW ACSW)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:CHARLES
Last Name:LUNDBLAD
Suffix:
Gender:M
Credentials:LMSW ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 HURON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3705
Mailing Address - Country:US
Mailing Address - Phone:810-985-7380
Mailing Address - Fax:810-985-3074
Practice Address - Street 1:824 HURON AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3705
Practice Address - Country:US
Practice Address - Phone:810-985-7380
Practice Address - Fax:810-985-3074
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801016861101Y00000X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR66572Medicare UPIN