Provider Demographics
NPI:1376640623
Name:LYNCH, MARY A (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:LYNCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ROUTE 111
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788
Mailing Address - Country:US
Mailing Address - Phone:631-560-2482
Mailing Address - Fax:
Practice Address - Street 1:900 ROUTE 111
Practice Address - Street 2:SUITE 210
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788
Practice Address - Country:US
Practice Address - Phone:631-560-2482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009154103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01044251Medicaid
NY01044251Medicaid