Healthcare Provider Details

I. General information

NPI: 1477895209
Provider Name (Legal Business Name): SHANNON LAURA LUNDY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CONSTITUTION AVE NE STE C
ALBUQUERQUE NM
87106-1243
US

IV. Provider business mailing address

2900 VISTA DEL REY NE UNIT 1B
ALBUQUERQUE NM
87112-8100
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-2353
  • Fax: 505-299-4740
Mailing address:
  • Phone: 505-379-2353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1259
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: