Provider Demographics
NPI:1366565301
Name:LUNDRIGAN, BRUCE KEVIN (LSW)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:KEVIN
Last Name:LUNDRIGAN
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-2814
Mailing Address - Country:US
Mailing Address - Phone:570-323-1020
Mailing Address - Fax:
Practice Address - Street 1:2200 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-2814
Practice Address - Country:US
Practice Address - Phone:570-323-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW124425104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018352400001Medicare ID - Type UnspecifiedMEDICAL ASSISSTANCE