Provider Demographics
NPI:1508919879
Name:LUNDVALL, KATHLEEN M (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:LUNDVALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:L
Other - Last Name:MCNAMARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:301 PALMETTO PARK BLVD
Mailing Address - Street 2:A
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7872
Mailing Address - Country:US
Mailing Address - Phone:803-359-3545
Mailing Address - Fax:803-359-2111
Practice Address - Street 1:301 PALMETTO PARK BLVD
Practice Address - Street 2:A
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7872
Practice Address - Country:US
Practice Address - Phone:803-359-3545
Practice Address - Fax:803-359-2111
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC165212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCF65494Medicare UPIN