Basic Information
| Provider Information | |||||||||
| NPI: | 1649373044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUNDBLAD | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | THEORDORE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | CLINICAL PSYCHOLOGIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 12TH PL SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039459840 | ||||||||
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| Address1: | 2695 12TH PL SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039452800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1688 | OR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.