Provider Demographics
NPI:1376683441
Name:KRIVDA, LYNN ANN
Entity Type:Individual
Prefix:MS
First Name:LYNN
Middle Name:ANN
Last Name:KRIVDA
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 1:1226 W OSBORN RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3618
Mailing Address - Country:US
Mailing Address - Phone:602-707-2511
Mailing Address - Fax:602-707-2040
Practice Address - Street 1:715 E MONTECITO AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4322
Practice Address - Country:US
Practice Address - Phone:602-707-2511
Practice Address - Fax:602-707-2040
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ685555Medicaid