Healthcare Provider Details

I. General information

NPI: 1134275738
Provider Name (Legal Business Name): CHARLES STAFFORD LUNDEN MS LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6151 E GRANT RD
TUC AZ
85712
US

IV. Provider business mailing address

6151 E GRANT RD
TUC AZ
85712
US

V. Phone/Fax

Practice location:
  • Phone: 520-722-9631
  • Fax: 520-722-9676
Mailing address:
  • Phone: 520-722-9631
  • Fax: 520-722-9676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLPC0333
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: