Provider Demographics
NPI:1508330903
Name:LUNDQUIST, STACEY KATHERYN (LGPC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:KATHERYN
Last Name:LUNDQUIST
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7316 BRAMBLEBUSH TER
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-9514
Mailing Address - Country:US
Mailing Address - Phone:646-532-8486
Mailing Address - Fax:
Practice Address - Street 1:3060 MICHELLVILLE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716
Practice Address - Country:US
Practice Address - Phone:410-893-4600
Practice Address - Fax:443-640-4358
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP8365101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor