Provider Demographics
NPI:1285836825
Name:WIERDSMA, LYNN (PSYD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:WIERDSMA
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 1:4279 IDEWILD LOOP APT 202
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-7155
Mailing Address - Country:US
Mailing Address - Phone:805-440-3135
Mailing Address - Fax:
Practice Address - Street 1:1115 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4936
Practice Address - Country:US
Practice Address - Phone:208-665-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60271238103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical