Provider Demographics
NPI:1114380565
Name:LYNCH, ANGELIQUE
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
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 1:3601 CUMMINGS RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2626
Mailing Address - Country:US
Mailing Address - Phone:216-544-6838
Mailing Address - Fax:
Practice Address - Street 1:24700 CHAGRIN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5647
Practice Address - Country:US
Practice Address - Phone:216-544-6838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-03
Last Update Date:2016-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.021414225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist