Provider Demographics
NPI:1124648100
Name:LUNDQUIST, DIANA LEIGH
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LEIGH
Last Name:LUNDQUIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 E 40TH ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23504-1007
Mailing Address - Country:US
Mailing Address - Phone:757-287-6817
Mailing Address - Fax:
Practice Address - Street 1:2107 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23324-3527
Practice Address - Country:US
Practice Address - Phone:757-494-7600
Practice Address - Fax:757-494-7573
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813001069103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool