Provider Demographics
NPI:1588996409
Name:LUNDEBERG, LESLEY (LCSW)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:LUNDEBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71350
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171
Mailing Address - Country:US
Mailing Address - Phone:801-580-4402
Mailing Address - Fax:801-484-6424
Practice Address - Street 1:262 E. 3900 S. #120
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106
Practice Address - Country:US
Practice Address - Phone:801-580-4402
Practice Address - Fax:801-484-6424
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5083529-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical