Healthcare Provider Details

I. General information

NPI: 1992463491
Provider Name (Legal Business Name): MRS. MELANIE MARIE LUNDEBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MELANIE MARIE TEGNER

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/01/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 KINKADE RD
BOARDMAN OR
97818
US

IV. Provider business mailing address

320 NE COLUMBIA AVE APT 106C
BOARDMAN OR
97818-9515
US

V. Phone/Fax

Practice location:
  • Phone: 541-481-2911
  • Fax:
Mailing address:
  • Phone: 503-586-4514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: