Provider Demographics
NPI:1992042337
Name:LUNDBOHM, BROOKE E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:E
Last Name:LUNDBOHM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 N PLANKINTON AVE STE 334
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2403
Mailing Address - Country:US
Mailing Address - Phone:414-271-5511
Mailing Address - Fax:
Practice Address - Street 1:740 N PLANKINTON AVE STE 334
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-2403
Practice Address - Country:US
Practice Address - Phone:414-271-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2823-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist