Provider Demographics
NPI:1942459243
Name:LUNDBERG, BRANDI DIANE (LMP)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:DIANE
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2681 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MANSON
Mailing Address - State:WA
Mailing Address - Zip Code:98831-9546
Mailing Address - Country:US
Mailing Address - Phone:506-970-8708
Mailing Address - Fax:
Practice Address - Street 1:2681 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MANSON
Practice Address - State:WA
Practice Address - Zip Code:98831-9546
Practice Address - Country:US
Practice Address - Phone:506-970-8708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA51449306225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist