Provider Demographics
NPI:1144503806
Name:LYNCH, THERESA (MS, OTRL)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:LYNCH
Suffix:
Gender:F
Credentials:MS, OTRL
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 10262
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34101-0262
Mailing Address - Country:US
Mailing Address - Phone:239-776-4001
Mailing Address - Fax:239-494-4365
Practice Address - Street 1:1044 CASTELLO DR STE 102
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-8981
Practice Address - Country:US
Practice Address - Phone:239-776-4001
Practice Address - Fax:239-494-4365
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007131225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1992712053Medicaid