Provider Demographics
NPI:1053646364
Name:GILDAR, LYN ASHLEY
Entity Type:Individual
Prefix:
First Name:LYN ASHLEY
Middle Name:
Last Name:GILDAR
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 1:4319 W BELL RD STE 4319
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3530
Mailing Address - Country:US
Mailing Address - Phone:602-888-0448
Mailing Address - Fax:844-578-8867
Practice Address - Street 1:4319 W BELL RD STE 4319
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3530
Practice Address - Country:US
Practice Address - Phone:602-888-0448
Practice Address - Fax:844-578-8867
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
AZ4587103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ017438Medicaid