Provider Demographics
NPI:1164870614
Name:LYNNE, SHAUNA
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:LYNNE
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 1:6701 PETERS CREEK RD STE 109
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-4060
Mailing Address - Country:US
Mailing Address - Phone:540-561-0890
Mailing Address - Fax:
Practice Address - Street 1:6701 PETERS CREEK RD STE 109
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-4060
Practice Address - Country:US
Practice Address - Phone:540-561-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05959103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist