Provider Demographics
NPI:1184059347
Name:LUNDGREN, TELEEA TAWNEE (LMT, NCTMB)
Entity type:Individual
Prefix:MRS
First Name:TELEEA
Middle Name:TAWNEE
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:LMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 DEER MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-9389
Mailing Address - Country:US
Mailing Address - Phone:971-235-4173
Mailing Address - Fax:
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:GRITMAN MEDICAL CENTER
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3056
Practice Address - Country:US
Practice Address - Phone:208-883-1522
Practice Address - Fax:208-883-6452
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1608225700000X
OR13897225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist