Healthcare Provider Details

I. General information

NPI: 1427930486
Provider Name (Legal Business Name): CONNIE NICHOLE LUNDGREN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 JUMER DR STE A
BLOOMINGTON IL
61704-0914
US

IV. Provider business mailing address

307 N PEARL ST
LE ROY IL
61752-1560
US

V. Phone/Fax

Practice location:
  • Phone: 309-463-5800
  • Fax: 833-914-2704
Mailing address:
  • Phone: 217-521-2671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.021777
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: