Provider Demographics
NPI:1144460189
Name:IRVIN, LYNN CORRIE (DO)
Entity type:Individual
Prefix:MS
First Name:LYNN
Middle Name:CORRIE
Last Name:IRVIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 N LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1942
Mailing Address - Country:US
Mailing Address - Phone:309-261-1509
Mailing Address - Fax:309-527-3999
Practice Address - Street 1:1508 N LINDEN ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-1942
Practice Address - Country:US
Practice Address - Phone:309-261-1509
Practice Address - Fax:309-527-3999
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILLI59770209P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist