Provider Demographics
NPI:1861596306
Name:LYNDE, ROSS SUTHERLAND (M ED, LPC)
Entity type:Individual
Prefix:MR
First Name:ROSS
Middle Name:SUTHERLAND
Last Name:LYNDE
Suffix:
Gender:M
Credentials:M ED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1359 WATERLILY RD
Mailing Address - Street 2:
Mailing Address - City:COINJOCK
Mailing Address - State:NC
Mailing Address - Zip Code:27923-9740
Mailing Address - Country:US
Mailing Address - Phone:252-207-2523
Mailing Address - Fax:252-453-2883
Practice Address - Street 1:1359 WATERLILY RD
Practice Address - Street 2:
Practice Address - City:COINJOCK
Practice Address - State:NC
Practice Address - Zip Code:27923-9740
Practice Address - Country:US
Practice Address - Phone:252-207-2523
Practice Address - Fax:252-453-2883
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4018101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC131UNOtherBCBS OF NC
NC6102435Medicaid