Provider Demographics
NPI:1083772925
Name:LYNN, DALE EDWARD (OTRL)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:EDWARD
Last Name:LYNN
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2605 NEW HARTFORD RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1316
Mailing Address - Country:US
Mailing Address - Phone:270-302-9795
Mailing Address - Fax:270-240-4840
Practice Address - Street 1:2605 NEW HARTFORD RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1316
Practice Address - Country:US
Practice Address - Phone:270-688-8449
Practice Address - Fax:270-240-4840
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY134498225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100268490Medicaid