Provider Demographics
NPI:1962865550
Name:LUNDSTROM HALLSTROM, ELIZA (LMT)
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:LUNDSTROM HALLSTROM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 SHORE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3154
Mailing Address - Country:US
Mailing Address - Phone:508-853-7500
Mailing Address - Fax:508-853-7505
Practice Address - Street 1:102 SHORE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3154
Practice Address - Country:US
Practice Address - Phone:508-853-7500
Practice Address - Fax:508-853-7505
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13305174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist