Provider Demographics
NPI:1366685513
Name:VIS, LYNNEA RENAE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LYNNEA
Middle Name:RENAE
Last Name:VIS
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:USS THEODORE ROOSEVELT MEDICAL DEPARTMENT
Mailing Address - Street 2:UNIT 100250 BOX 2736
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96632
Mailing Address - Country:US
Mailing Address - Phone:571-442-4247
Mailing Address - Fax:
Practice Address - Street 1:901 W GUNNISON ST # 2E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4210
Practice Address - Country:US
Practice Address - Phone:571-442-4247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810006182103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical