Provider Demographics
NPI:1609540889
Name:LUNDGREN, BRENNAN D
Entity Type:Individual
Prefix:
First Name:BRENNAN
Middle Name:D
Last Name:LUNDGREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5736 CHARLESTON ST
Mailing Address - Street 2:
Mailing Address - City:DANIA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33021
Mailing Address - Country:US
Mailing Address - Phone:954-512-8284
Mailing Address - Fax:
Practice Address - Street 1:5736 CHARLESTON ST
Practice Address - Street 2:
Practice Address - City:DANIA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33021-3302
Practice Address - Country:US
Practice Address - Phone:954-512-8284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA85903225700000X
FLMA85903225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist