Provider Demographics
NPI:1215589858
Name:TULLOCH, LYN C (LMSW)
Entity Type:Individual
Prefix:MR
First Name:LYN
Middle Name:C
Last Name:TULLOCH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 LAFAYETTE AVE APT 7L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-7263
Mailing Address - Country:US
Mailing Address - Phone:646-221-5673
Mailing Address - Fax:
Practice Address - Street 1:1946 WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-4249
Practice Address - Country:US
Practice Address - Phone:718-294-1715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065240104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty