Provider Demographics
NPI:1942541297
Name:LUNDGREN, TRYGVE (OTR/L)
Entity Type:Individual
Prefix:
First Name:TRYGVE
Middle Name:
Last Name:LUNDGREN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10500 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3801 HART BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-4106
Practice Address - Country:US
Practice Address - Phone:763-210-6697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104416225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist