Provider Demographics
NPI:1912038522
Name:LUNDGREN, VICKI - (MFT)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:-
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 WOODS ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-3417
Mailing Address - Country:US
Mailing Address - Phone:831-426-2134
Mailing Address - Fax:
Practice Address - Street 1:412 CEDAR ST
Practice Address - Street 2:STE. B
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4369
Practice Address - Country:US
Practice Address - Phone:831-426-6710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30425106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist