Basic Information
Provider Information | |||||||||
NPI: | 1194740092 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LUNDIN | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | OSCAR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, LLP, LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 28000 DEQUINDRE RD | ||||||||
Address2: |   | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480922468 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5867530405 | ||||||||
FaxNumber: | 5867530404 | ||||||||
Practice Location | |||||||||
Address1: | 3950 S ROCHESTER RD | ||||||||
Address2: | #1400 | ||||||||
City: | ROCHESTER HILLS | ||||||||
State: | MI | ||||||||
PostalCode: | 483075160 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2488446234 | ||||||||
FaxNumber: | 2488446237 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 01/24/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401008300 | MI | Y |   | Behavioral Health & Social Service Providers | Counselor |   | 103T00000X | 6301011987 | MI | N |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.