Provider Demographics
NPI:1053813493
Name:LYNN, NOELLE
Entity Type:Individual
Prefix:
First Name:NOELLE
Middle Name:
Last Name:LYNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NOELLE
Other - Middle Name:
Other - Last Name:GORNIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1040 LAFAYETTE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1107
Mailing Address - Country:US
Mailing Address - Phone:616-250-4360
Mailing Address - Fax:616-245-0450
Practice Address - Street 1:2025 E BELTLINE AVE SE STE 301
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7634
Practice Address - Country:US
Practice Address - Phone:616-250-4360
Practice Address - Fax:616-258-2214
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIN8944101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical