Provider Demographics
NPI:1518184191
Name:LUNDSTROM, SAMANTHA CONNOLLY (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:CONNOLLY
Last Name:LUNDSTROM
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MRS
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:CONNOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:22 FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02724
Mailing Address - Country:US
Mailing Address - Phone:508-678-8590
Mailing Address - Fax:
Practice Address - Street 1:22 FLORIDA ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02724-2803
Practice Address - Country:US
Practice Address - Phone:508-678-8590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8029225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist