Provider Demographics
NPI:1548452139
Name:LUNDSTROM, JOANNE R (COTA/L)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:R
Last Name:LUNDSTROM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 ROYAL GLEN DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-2493
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:471 W TERRA COTTA AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3434
Practice Address - Country:US
Practice Address - Phone:815-455-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant