Provider Demographics
NPI:1558426411
Name:LUNDBLAD, CONCHITA SMITH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CONCHITA
Middle Name:SMITH
Last Name:LUNDBLAD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12810 SW 105TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-3503
Mailing Address - Country:US
Mailing Address - Phone:305-270-6799
Mailing Address - Fax:305-271-1757
Practice Address - Street 1:10300 SW 72ND ST STE 152
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3000
Practice Address - Country:US
Practice Address - Phone:305-270-6799
Practice Address - Fax:305-271-1757
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW15371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z2309Medicare ID - Type Unspecified