Provider Demographics
NPI:1902164791
Name:ANDERSON, LYNN
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:ANDERSON
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 1:107 E 2ND ST
Mailing Address - Street 2:1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-7936
Mailing Address - Country:US
Mailing Address - Phone:772-539-2070
Mailing Address - Fax:
Practice Address - Street 1:74 TRINITY PL
Practice Address - Street 2:612
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-2003
Practice Address - Country:US
Practice Address - Phone:212-285-0043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000649106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist