Provider Demographics
NPI:1124182738
Name:VICE, LYNN ANN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:ANN
Last Name:VICE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 N LAKE DR
Mailing Address - Street 2:SUITE 409
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4528
Mailing Address - Country:US
Mailing Address - Phone:414-271-7442
Mailing Address - Fax:414-271-7530
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:SUITE 409
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-271-7442
Practice Address - Fax:414-271-7530
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI910103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39026600Medicaid