Provider Demographics
NPI:1891013777
Name:LUNDAHL, SHILOH (LCSW)
Entity Type:Individual
Prefix:MR
First Name:SHILOH
Middle Name:
Last Name:LUNDAHL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3048 E BASELINE RD. STE 108
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204
Mailing Address - Country:US
Mailing Address - Phone:602-492-5055
Mailing Address - Fax:480-558-3020
Practice Address - Street 1:6402 E SUPERSTITION SPRINGS BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4392
Practice Address - Country:US
Practice Address - Phone:480-668-8301
Practice Address - Fax:480-558-3020
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-133551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical