MEDICARE: MRS. BRENDA COLE LUNDIE LCSW

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	101Y00000X	Counselor	0904003631	VA

General Provider Information

NPI Number	:	1558685222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRENDA COLE LUNDIE LCSW

Provider Business Mailing Address
First Line	:	17201 JEFFERSON DAVIS HIGHWAY
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834
Country	:	US
Telephone Number	:	804-526-0424
Fax Number	:	804-526-0748

Provider Business Practice Location Address
First Line	:	17201 JEFF. DAVIS HWY
Second Line	:
City	:	COL. HGTS
State	:	VA
Zip	:	23834
Country	:	US
Telephone Number	:	804-526-0424
Fax Number	:

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

Provider Enumeration Date	:	03/24/2010
Last Update Date	:	03/24/2010

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