Provider Demographics
NPI:1770686073
Name:LUNDHOLM, GLORIA (LMFT)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:LUNDHOLM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1859
Mailing Address - Street 2:
Mailing Address - City:KINGS BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:96143-1859
Mailing Address - Country:US
Mailing Address - Phone:530-546-4985
Mailing Address - Fax:530-546-0815
Practice Address - Street 1:7836 PINEDROP LANE
Practice Address - Street 2:
Practice Address - City:TAHOE VISTA
Practice Address - State:CA
Practice Address - Zip Code:96148
Practice Address - Country:US
Practice Address - Phone:530-546-4985
Practice Address - Fax:530-546-0815
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15968106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist