Provider Demographics
NPI:1053629154
Name:LYNCH, LISA L
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:L
Last Name:LYNCH
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 1:3351 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13416-3213
Mailing Address - Country:US
Mailing Address - Phone:315-853-6090
Mailing Address - Fax:315-853-3190
Practice Address - Street 1:2 FOUNTAIN ST
Practice Address - Street 2:SUTITE 109
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1725
Practice Address - Country:US
Practice Address - Phone:315-853-6090
Practice Address - Fax:315-853-3190
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003345-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency