Healthcare Provider Details

I. General information

NPI: 1699722546
Provider Name (Legal Business Name): JANICE ANNETTE LUNDEEN CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 W BROADWAY ST. SUITE G.
IDAHO FALLS ID
83402-2902
US

IV. Provider business mailing address

2 VIRGINIA ST
PHENIX CITY AL
36869-5436
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-7400
  • Fax: 208-534-5715
Mailing address:
  • Phone: 406-250-9574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-41069
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number008823
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: