Provider Demographics
NPI: | 1245598499 |
---|---|
Name: | LYNDA S. WALLS, PH.D., INC. |
Entity Type: | Organization |
Organization Name: | LYNDA S. WALLS, PH.D., INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | LYNDA |
Authorized Official - Middle Name: | SMITH |
Authorized Official - Last Name: | WALLS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PHD |
Authorized Official - Phone: | 904-536-8095 |
Mailing Address - Street 1: | 13018 VIBURNUM DR N |
Mailing Address - Street 2: | |
Mailing Address - City: | JACKSONVILLE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32246-1144 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 904-536-8095 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 931 CASSAT AVE |
Practice Address - Street 2: | |
Practice Address - City: | JACKSONVILLE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32205-4857 |
Practice Address - Country: | US |
Practice Address - Phone: | 904-388-2828 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-04-25 |
Last Update Date: | 2012-04-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | 4887 | 103T00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Single Specialty |