Provider Demographics
NPI:1427930486
Name:LUNDGREN, CONNIE NICHOLE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:NICHOLE
Last Name:LUNDGREN
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 1:307 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:LE ROY
Mailing Address - State:IL
Mailing Address - Zip Code:61752-1560
Mailing Address - Country:US
Mailing Address - Phone:217-521-2671
Mailing Address - Fax:
Practice Address - Street 1:1709 JUMER DR STE A
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-0914
Practice Address - Country:US
Practice Address - Phone:309-463-5800
Practice Address - Fax:833-914-2704
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-22
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.021777101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional