MEDICARE: DR. SANDRA LYNN LUNDBERG PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	2505	CO

General Provider Information

NPI Number	:	1083822399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDRA LYNN LUNDBERG PSY.D.

Provider Business Mailing Address
First Line	:	4797 SPOTTED HORSE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-5195
Country	:	US
Telephone Number	:	719-262-9813
Fax Number	:

Provider Business Practice Location Address
First Line	:	6165 LEHMAN DR
Second Line	:	SUITE 106
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3441
Country	:	US
Telephone Number	:	719-641-3880
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	07/08/2007

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