Provider Demographics
NPI:1932200706
Name:LUNDBLAD, BETH A (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:LUNDBLAD
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-1915
Mailing Address - Country:US
Mailing Address - Phone:260-471-6336
Mailing Address - Fax:
Practice Address - Street 1:7333 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6280
Practice Address - Country:US
Practice Address - Phone:260-435-6230
Practice Address - Fax:260-435-7747
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003635225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist