Provider Demographics
NPI:1659958023
Name:LUNDHOLM, LINDSEY MARGUERITE
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:MARGUERITE
Last Name:LUNDHOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 SUMMERWILD AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84321-5541
Mailing Address - Country:US
Mailing Address - Phone:208-270-9721
Mailing Address - Fax:
Practice Address - Street 1:638 SUMMERWILD AVE
Practice Address - Street 2:
Practice Address - City:RIVER HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84321-5541
Practice Address - Country:US
Practice Address - Phone:208-270-9721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-19-85503106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician