Provider Demographics
NPI:1538778964
Name:LUNDMARK, TARA KATHRYN (MA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:KATHRYN
Last Name:LUNDMARK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 TOMOKA BLVD S
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-8123
Mailing Address - Country:US
Mailing Address - Phone:218-831-7232
Mailing Address - Fax:
Practice Address - Street 1:125 TOMOKA BLVD S
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-8123
Practice Address - Country:US
Practice Address - Phone:218-831-7232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9652235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist