Provider Demographics
NPI:1043239676
Name:LYNCH, KERRY WAYNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:WAYNE
Last Name:LYNCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53295-0001
Mailing Address - Country:US
Mailing Address - Phone:414-384-2000
Mailing Address - Fax:414-382-5298
Practice Address - Street 1:8380 NORTH ST.
Practice Address - Street 2:
Practice Address - City:IXONIA
Practice Address - State:WI
Practice Address - Zip Code:53036
Practice Address - Country:US
Practice Address - Phone:262-569-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1458057103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14580057OtherPSYCHOLOGIST