Provider Demographics
NPI:1376192179
Name:LYNCH, ANDREA L
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:LYNCH
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 1:51 TACONIC AVE
Mailing Address - Street 2:
Mailing Address - City:LENOX
Mailing Address - State:MA
Mailing Address - Zip Code:01240-2348
Mailing Address - Country:US
Mailing Address - Phone:413-637-1300
Mailing Address - Fax:866-230-7304
Practice Address - Street 1:51 TACONIC AVE
Practice Address - Street 2:
Practice Address - City:LENOX
Practice Address - State:MA
Practice Address - Zip Code:01240-2348
Practice Address - Country:US
Practice Address - Phone:413-637-1300
Practice Address - Fax:866-230-7304
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111701-SW-LICSW104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA111701-SW-LICSWOtherDEPT OF PROFESSIONAL LICENSURE