Provider Demographics
NPI:1720562671
Name:LUND-TACK, CRISTINA M
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:M
Last Name:LUND-TACK
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 1:6 BYRD AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-1626
Mailing Address - Country:US
Mailing Address - Phone:508-561-8329
Mailing Address - Fax:
Practice Address - Street 1:146 MAPLE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-2504
Practice Address - Country:US
Practice Address - Phone:781-861-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1157731041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool