Provider Demographics
NPI:1972935047
Name:LUNDBLADE, CARLA (MS LPC NCC)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:LUNDBLADE
Suffix:
Gender:F
Credentials:MS LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7332
Mailing Address - Country:US
Mailing Address - Phone:541-951-9517
Mailing Address - Fax:541-423-5470
Practice Address - Street 1:14 COTTAGE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7332
Practice Address - Country:US
Practice Address - Phone:541-951-9517
Practice Address - Fax:541-423-5470
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2874101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional