Provider Demographics
NPI:1578288643
Name:LUNDGREN, COLLEEN MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTONAGON
Mailing Address - State:MI
Mailing Address - Zip Code:49953-1451
Mailing Address - Country:US
Mailing Address - Phone:906-884-6054
Mailing Address - Fax:
Practice Address - Street 1:730 S 7TH ST
Practice Address - Street 2:
Practice Address - City:ONTONAGON
Practice Address - State:MI
Practice Address - Zip Code:49953-1451
Practice Address - Country:US
Practice Address - Phone:906-884-6054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002101225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant