Provider Demographics
NPI:1295453553
Name:LUNDGREN, ALEXANDRA GAIL (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:GAIL
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:GAIL
Other - Last Name:MASHBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1783 KAISER DR
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2879
Mailing Address - Country:US
Mailing Address - Phone:850-368-5904
Mailing Address - Fax:
Practice Address - Street 1:7155 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-7893
Practice Address - Country:US
Practice Address - Phone:614-833-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.20222115.SP235Z00000X
OHSP.15484235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist