Healthcare Provider Details

I. General information

NPI: 1194862839
Provider Name (Legal Business Name): MS. TAMMY MARIE LUNDBOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2714 NE 205TH AVE APT 228
FAIRVIEW OR
97024-9649
US

IV. Provider business mailing address

2714 NE 205TH AVE APT 228
FAIRVEW OR
97024
US

V. Phone/Fax

Practice location:
  • Phone: 503-914-9768
  • Fax:
Mailing address:
  • Phone: 503-914-9768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: