Basic Information
| Provider Information | |||||||||
| NPI: | 1639762578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUNHAM | ||||||||
| FirstName: | LODEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3101 LATHROP ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997017426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074594700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3101 LATHROP ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997017426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074594700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2021 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.