Provider Demographics
NPI:1720807159
Name:LUNDSTROM, DANA NICOLE (RBT)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:NICOLE
Last Name:LUNDSTROM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3551
Mailing Address - Country:US
Mailing Address - Phone:309-452-0069
Mailing Address - Fax:
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:309-452-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-350790106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician