=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205198199
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WYNNE LUNDBLAD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2012
-----------------------------------------------------
Last Update Date | 03/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3811 OHARA ST WESTERN PSYCHIATRIC INSTITUTE AND CLINIC
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15213-2561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-246-5320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3811 O'HARA ST WESTERN PSYCHIATRIC INSTITUTE AND CLINIC
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15213-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 453856
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------