Provider Demographics
NPI:1598144230
Name:LUNDSTROM, SUSAN (PTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LUNDSTROM
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 1:898 MASSACHUSETTS AVE
Mailing Address - Street 2:#34
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-4735
Mailing Address - Country:US
Mailing Address - Phone:781-643-1469
Mailing Address - Fax:
Practice Address - Street 1:898 MASSACHUSETTS AVE
Practice Address - Street 2:#34
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4735
Practice Address - Country:US
Practice Address - Phone:781-643-1469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6117225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant