Provider Demographics
NPI:1619261906
Name:LUNDBERG, GRANT M (DPT)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:M
Last Name:LUNDBERG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DENNIS ST SW
Mailing Address - Street 2:STE B
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-6523
Mailing Address - Country:US
Mailing Address - Phone:303-790-4495
Mailing Address - Fax:720-488-1988
Practice Address - Street 1:5905 N MAYFAIR ST STE 100
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1127
Practice Address - Country:US
Practice Address - Phone:509-462-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60725120225100000X
CO11859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist