Provider Demographics
NPI:1568601201
Name:LUNDWALL, CAROL L (CPCI)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:L
Last Name:LUNDWALL
Suffix:
Gender:F
Credentials:CPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 S 300 E APT 524
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2416
Mailing Address - Country:US
Mailing Address - Phone:801-949-2591
Mailing Address - Fax:
Practice Address - Street 1:3809 S WEST TEMPLE STE 1B
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-4479
Practice Address - Country:US
Practice Address - Phone:801-268-4454
Practice Address - Fax:801-268-2176
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4925810-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health